Fillable Online azdhs PM Form 3 14 1 CON 8-1-07 FINAL 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering the 'Date and Time of CON' in the designated fields. Ensure accuracy as this is crucial for processing.
3. Select the 'Type of Service Requested' by checking the appropriate box for either Psychiatric Acute Hospital, Residential Treatment Center, or Sub-acute Facility.
4. Fill in the 'Client Information' section with the client's name, address, AHCCCS ID, date of birth, and provider phone number.
5. Provide a numeric diagnosis per ICD 10 criteria in the specified field.
6. In the text boxes provided, explain why inpatient services are necessary and how they will improve the client’s condition.
7. The physician must sign and print their name in the designated area and date it appropriately.
8. Complete the 'Proposed Placement' section with Level I Provider Name and requested admission dates.
9. Finally, ensure all information is accurate before submitting. If required, fax to AHCCCS along with any additional forms.

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