Request to Add Counties to Existing Service Site Form 2025

1. Click ‘Get Form’ to open the Request to Add Counties to Existing Service Site Form in our editor.
2. Begin by entering the legal name of your organization in the designated field at the top of the form.
3. Next, provide the APS Audit Scores. Fill in the last two scores along with their respective dates in the provided sections.
4. Indicate the service type and population served by selecting either 'Adults' or 'C&A' from the options available.
5. Complete the site information fields, including Site Name, Street Address, City, State, County, Zip Code, and Site Telephone Number.
6. Specify any additional counties you wish to serve from this site within a 50-mile radius in the appropriate section.
7. Fill out your details as the requester, including your name, title, signature, and date at the bottom of the form.
8. Ensure you attach an updated organizational chart and copies of professional certificates/licenses for all credentialed staff before submission.

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