DCS Forms

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Download Number Form Name Effective Date
Microsoft Office document icon Download (43.5 KB) DCS-1041A-S HIPAA Privacy Complaint Confirmation of Receipt (Spanish) 08/01/2014
Microsoft Office document icon Download (67 KB) DCS-1050A-S Accounting Disclosure Tracking (Spanish) 08/01/2014
Microsoft Office document icon Download (40.5 KB) DCS-1042A Response to HIPAA Privacy Complaint 08/01/2014
Microsoft Office document icon Download (50.5 KB) DCS-1051A Request for an Accounting of Disclosures of Protected Health 08/01/2014
Microsoft Office document icon Download (39.5 KB) CSO-1006A Dentist's Certification of Medical Necessity 07/01/2014
PDF icon Download (61.56 KB) CRS App Span Application for Enrollment into AHCCCS CRS (Spanish) 09/01/2013
PDF icon Download (135.05 KB) Dental Matri Dental Matrix (CMDP) 01/01/2013