PATIENT REGISTRATION FORM Date:

Referred By: ☐ PHYSICIAN ☐ FAMILY/FRIEND ☐ OTHER Enter REFERRAL’s Name:

PATIENT’s Name (First) (MI) (Last)

Date of Birth: Age: Sex: ☐M ☐ F Social Security #: If Patient is a Minor, enter MOTHER’s Full Name

Patient lives with both Parents? ☐Y ☐ N

FATHER’s Full Name LEGAL GUARDIAN’s Full Name

Address (Street)

City State ZIP

Home Phone #: Cell Phone #: Work Phone#:

Email Address: Preferred Language:

Preferred Communication Method: ☐Home ☐Cell ☐Text ☐Email ☐Postal Mail ☐Work

EMPLOYER Name & Address:

If Student, SCHOOL Name: Responsible Person for Account Balance Payments:

Responsible Person’s Date of Birth:

PHARMACY Name: Pharmacy Phone No.:

By signing below, I (the Patient or Legal Representative), provide my consent to allow Bayless Integrated Healthcare and its Partners/Business Associates to leave information related to services provided to the Patient named above via the preferred Primary Communication Preference as marked above. In granting this permission, I understand that some of the messages may contain Protected Health Information (PHI) concerning the Patient. I understand that if no preferred method is marked, messages will automatically be delivered via postal mail to the home address on record when appropriate.

PRIMARY CARE PROVIDER (PCP) INFORMATION

Primary Care Provider Name: ______________________________________________ Phone No.: ____________________________

EMERGENCY CONTACT INFORMATION

Emergency Contact Person: Phone No.:

Relationship to Patient:

INSURANCE INFORMATION (COPIES OF INSURANCE CARDS REQUIRED)

☐ CHECK BOX ONLY IF PATIENT, BOTH PARENTS, OR LEGAL GUARDIAN/RESPONSIBLE PARTY DOES NOT HAVE INSURANCE.

PRIMARY Insurance: Effective Date:

Name of INSURED/SUBSCRIBER: Relationship to Patient:

Insured’s Date of Birth: Insured’s Member ID: Group No.:

Insured’s SSN: Insured’s Home Address:

Insured’s Phone No.: Insured Employed By:

Insured’s Employer Address: Insured’s Employer Phone:

SECONDARY Insurance: Effective Date:

Name of INSURED/SUBSCRIBER: Relationship to Patient:

Insured’s Date of Birth: Insured’s Member ID: Group No.:

Insured’s SSN: Insured’s Home Address:

Insured’s Phone No.: Insured Employed By:

Insured’s Employer Address: Insured’s Employer Phone:

I am responsible for keeping my contact information up-to-date. If there are any changes to my contact information including address and insurance information, I will notify the office staff at Bayless Integrated Healthcare of such changes to ensure the privacy of my medical and/or behavioral health information.

Print Responsible Party’s Name:______________________________________ Relationship to Patient:____________________

Responsible Party’s Signature:_______________________________________ Date:_____________________

RE-FRM001.00-A (11/17)

CONSENT FOR EVALUATION AND/OR TREATMENT AND TO USE & DISCLOSE HEALTH INFORMATION

Patient’s Name: Date of Birth:

PS-FRM002.00-A (11/17)

I authorize Bayless Integrated Healthcare to provide evaluation and treatment services to the patient named above.

I agree to participate in my treatment planning process to the best of my ability and will let my provider know if situations occur that prevent me from participating in treatment.

I understand this consent will remain valid as long as I am enrolled with Bayless Integrated Healthcare.

I understand by signing this consent form, I am giving permission to all members of my Bayless Integrated Healthcare clinical treatment team and my insurance payer to access my information and records.

I understand that all of the information gathered in the course of my treatment is confidential. However, confidential information may be disclosed without my consent in accordance with state and federal law.

I understand that services are for treatment purposes only and will not be used for any or all legal matters.

Print Patient or Legal Guardian/Representative’s Name Relationship to Patient

Patient’s or Legal Guardian/Representative’s Signature Date

CASES INVOLVING CUSTODY- POLICY & ACKNOWLEDGMENT

Bayless Integrated Healthcare is not an agency that works with custody issues. Staff members at BIH will provide appropriate levels of medical and/or behavioral health care to your child and family; however, staff members are not permitted to make custody recommendations nor act as custody experts for any person or group associated with the case. By signing this document, you (the Patient or Patient’s Legal Representative) is acknowledging that you

understand and agree with this policy.

Print Patient or Legal Guardian/Representative’s Name Relationship to Patient

Patient’s or Legal Guardian/Representative’s Signature Date

FINANCIAL POLICY & ACKNOWLEDGMENT

Our payment policy is to collect the appropriate payment due from the Patient at the time the service is rendered. This may only be the Patient’s copayment, deductible, and/or coinsurance, sliding fee, or full payment; but we do ask for payment at the time of visit. We accept the following forms of payment: Cashier’s Check, Money Order, Debit Card, Discover/Visa/AmEx/MasterCard at any of our office locations. Forms of payment that are not accepted at our office locations are personal checks and cash. When Patient pays for account balance with personal check and his/her check is returned due to insufficient funds, we will charge a $30 Returned Check fee on all returned checks.

Patient’s or Legal Guardian/Representative’s Signature Date

AUTHORIZATION FOR USE OF HEALTH INFORMATION

Patient’s Name: Date of Birth:

MR-FRM001.00-A (11/17)

E-PRESCRIBING CONSENT

Bayless Integrated Healthcare (BIH) has implemented electronic prescribing (also known as e-prescribing) for its patients. E-Prescribing involves the ability for the practice to send prescriptions electronically to pharmacies.

By signing this Release of Health Information Consent Form, I (the Patient or Patient’s Legal Representative) am agreeing that Bayless Integrated Healthcare can request and use the prescription medication history from other healthcare providers and/or third party pharmacy benefit payers for treatment purposes for the Patient named above.

DISCLOSURES TO ASIIS & SCHOOLS

Arizona State Immunization Information System (ASIIS) is a computer based immunization registry and tracking system implemented by the Arizona Department of Health Services (ADHS) and its partners. By law we are required to report to ASIIS immunizations administered to children “birth to 18” years of age.

By signing this Release of Information Consent Form, I (the Patient or Patient’s Legal Representative) am agreeing to the release information about all vaccinations given to the Patient named above to ASIIS in order to avoid receiving unnecessary vaccinations and to schools requiring proof of immunization. I understand that I am not required to agree to the release of this information in order to receive the vaccinations I request.

MESSAGING SERVICES AUTHORIZATION

Bayless Integrated Healthcare (BIH) will send notifications to our patients using an electronic communication including but not limited to text messages, emails, and/or automated calls through our Electronic Health Record (EHR) system. This will assist the practice in carrying out treatment, payment and health care operations (TPO), such as appointment reminders, any calls pertaining to my clinical care, including laboratory test results, and patient statements among others. By signing below, I authorize Bayless Integrated Healthcare (BIH) and its Partners/Business Associates to release my Protected Health Information (PHI) electronically or by postal mail. If at any time I wish to revoke the use of electronic communication I will notify the staff at Bayless Integrated Healthcare.

DISCLOSURES TO FAMILY MEMBERS & FRIENDS

Disclosures related to the patient’s health (both medical and behavioral health-related) may be made to family and friends or as needed for payment of health care services. We will only disclose information relevant to Patient’s current treatment.

I provide my consent to allow BIH to disclose my health care information to: ☐ DO NOT DISCLOSE TO ANYONE.

Print Name Phone Number Relationship to Patient

Print Name Phone Number Relationship to Patient

Understanding all of the above, I (the Patient or Patient’s Legal Representative) hereby provide my signature below to give my consent to Bayless Integrated Healthcare (BIH) and its Partners/Business Associates to release my medical and/or behavioral health-related information according to the e-Prescribing Program, ASIIS & Schools, and Disclosures to Family Members & Friends sections mentioned above. I have the right to review the Notice of Privacy Practices prior to signing this consent. I have the right to request that BIH restrict how it uses or discloses my PHI to carry out treatment, payment and health care operations (TPO). The practice is not required to agree to my requested restrictions, but if it does, it is bound by their agreement. I am also aware that I may revoke my consent by submitting a written request to BIH at any time except to the extent that the practice has already made disclosures in reliance upon my prior consent. I have had the chance to ask questions and all of my questions have been answered to my satisfaction.

Print Patient or Legal Guardian/Representative’s Name Relationship to Patient

Patient’s or Legal Guardian/Representative’s Signature Date

CONSENT FOR PCP TWO-WAY RELEASE/REQUEST OF PROTECTED HEALTH INFORMATION

MR-FRM003.00-A (11/17)

I, PRINT PATIENT’S NAME PATIENT’S DATE OF BIRTH

request and authorize Bayless Integrated Healthcare (BIH) to:

☐ EXCHANGE WITH ☐ RECEIVE FROM ☐ PROVIDE TO

NAME OF AGENCY OR PERSON TO PROVIDE OR RECEIVE INFORMATION

PRINT NAME OF AGENCY OR PERSON AGENCY’S OR RECEIVING PERSON’S PHONE NO.

I REQUEST MY HEALTH INFORMATION (IN WRITTEN, ELECTRONIC, AND/OR ORAL FORM) REGARDING THE FOLLOWING: NOTE: Mark the box(es) next to the information below that are to be shared or released. ☒ PCP Communication/Coordination of Care ☐ Future Appointment Date of Appointment:

☒ Requesting MEDICAL records (Specify type[s] below): ☒ Requesting BEHAVIORAL HEALTH records (Specify type[s] below):

☐ Copies of records of the last two (2) years of treatment ☐ Copies of records covering dates FROM: TO

☒ Lab Results (Dates): ☒ Diagnostic Test Results (Dates): ☒ X-rays (Dates):

☒ Initial Evaluation & Recommendation

☒ Diagnosis & Assessment

☒ Medical History

☒ Medication List

☒ Immunization Records

☒ Physical Exam Notes

☒ Preventative Care Services Notes

☒ Office Visit/Progress Notes

☒ Treatment Plan for Medical Services

☒ Physician Orders

☒ Current/Complete EPSDT forms

☒ Hospital Discharge Summary

☒ Emergency/Urgent Care Reports

☐ Treatment Summary/Service Plans

☐ Duration of Treatment or Program

☒ Certification of Need (CON)

☒ Re-Certification of Need (RON)

☒ BHMP Notes

☒ RN Notes

☒ Consultation Notes

☐ Psychological Evaluation

☐ Psychiatric Assessment/Evaluations

☒ Radiology Reports for Requested X-Rays

☒ Summary of Treatment Participation/Progress

☒ Documentation of Facility-based/In-Patient Care

☒ Pharmacy Prescriptions/Medication Profile

☐ Social Skills & Behavioral at School

☐ Academic Performance

☒ Dental History, Dental Needs and/or Services

☐ Financial/Insurance Information

☐ Appointment Times/Attendance

☐ Requests for Service Authorizations

☐ Other (please specify):

THE HEALTH INFORMATION MARKED ABOVE IS FOR THE PURPOSE OF:

NOTE: Mark the box(es) that apply to the purpose of this authorized release. ☐ Planning and implementing therapy for the client and/or client’s family ☐ Transferring information regarding previous treatment ☐ Assisting with the client’s/patient’s evaluation and treatment

☒ Coordinating services between Bayless Integrated Healthcare (BIH) and agency or person named above

☐ Determining if Bayless Integrated Healthcare (BIH) services are appropriate for the client’s needs RIGHT TO REVOKE CONSENT

By signing below, I acknowledge that I understand that I have the right to revoke this consent at any time. The revocation must be provided in writing to Medical Records at BIH. I understand that the revocation will not apply to information that has already been released in response to this consent.

CONSENT ACKNOWLEDGEMENT

By signing below, I authorize the Agency or Person identified above to send and/or receive copies of the records and/or reports to and/or from Bayless Integrated Healthcare (BIH). If sending records and/or reports to BHG, please send to the following address: ATTN: MEDICAL RECORDS BAYLESS INTEGRATED HEALTHCARE (BIH) 3620 N 3RD STREET PHOENIX, AZ 85012 PH: (602) 230-7373 / FAX: (602) 682-7455

The requested medical and/or behavioral health record copies may include the following CONFIDENTIAL Protected Health Information: HIV-RELATED INFORMATION, COMMUNICABLE DISEASE-RELATED INFORMATION, PSYCHOTHERAPY NOTES, GENETIC TESTING INFORMATION, AND ALCOHOL AND/OR DRUG ABUSE TREATMENT PROGRAM INFORMATION

NOTE: If this release pertains to CONFIDENTIAL Protected Health Information indicated above, please note that the information has been disclosed to the above-named Recipient from records protected by the State of Arizona (as defined in A.R.S. SECTIONS 12-2801, 36-661, & 36-664) and federal confidentiality rules (42 CFR §2.1 & 45 CFR §164.501). The state (A.R.S. SECTION 12-2294) and federal rules (45 CFR §164.508) prohibit the above-named Recipient from making any further disclosure of this information unless additional further disclosure is expressly permitted by written consent of the person to whom it pertains or as otherwise permitted by 42 CFR §164.502. A general consent or authorization for the release of other information is NOT sufficient for this purpose. The federal rules also restrict any use of the information to criminally investigate or prosecute any alcohol or drug abuse patient. BHG employees and/or agents will not condition treatment, payment, enrollment, or eligibility for benefits on whether the individual signs a consent form OR we will describe the consequences of refusal to sign a consent form.

I hereby release and agree to indemnify Bayless Integrated Healthcare (BIH), its physicians, employees, affiliates, successors and assignees, and their respective employees, trustees and agents from and against any and all liability, including reasonable attorneys’ fees, arising out of the exercise of the rights granted by this consent for release of the above-named Recipient’s Protected Health Information (PHI). I have given my consent freely, voluntarily, and without coercion. I understand it is possible that the information in my medical and/or behavioral health records may be disclosed by the Recipient to other parties. I may inspect and may receive a copy of the information to be disclosed. I understand that this consent is effective as of the signed date below and will remain in effect until the Patient provides a revocation notice to BIH in writing as mentioned above. I may revoke this consent at any time providing I notify Bayless Integrated Healthcare in writing to that effect. I understand that any releases, which were made prior to my revocation in compliance with this consent, shall not constitute a breach of my rights to confidentiality. Certain information concerning a minor is governed by the State of Arizona and Federal statutes and will require the minor’s signature prior to any release. I understand that a photocopy or facsimile of this signed consent form is considered acceptable in lieu of the original.

NOTE: If patient is between 12-18 years of age, his/her signature is preferred along with required signatures of parent or legal guardian.

PATIENT SIGNATURE:

DATE:

PRINT PARENT/LEGAL GUARDIAN/POWER OF ATTORNEY NAME:

RELATIONSHIP TO PATIENT:

PARENT/LEGAL GUARDIAN/POWER OF ATTORNEY SIGNATURE:

WITNESS/NOTARY:

DATE:

NOTICE OF PRIVACY PRACTICES, PATIENT RIGHTS FINANCIAL POLICY & ACC HEALTH PLAN HANDOUT RECEIPT ACKNOWLEDGEMENT

Patient’s Name: Date of Birth:

PS-FRM001.02-A (10/18)

RECEIPT ACKNOWLEDGEMENT OF PRIVACY AND PATIENT RIGHTS, FINANCIAL POLICY & ACC HANDOUT

Bayless Integrated Healthcare’s Notice of Privacy Practices (NPP) provides information about how we may use and disclose protected health information (PHI) about you. As provided in our notice, the terms of our notice may change. If we change our notice, you may obtain a revised copy. I understand that I may ask questions if I do not understand any information contained in the Notice of Privacy Practices, Patient’s Rights and Grievance Policy, or Financial Policy.

By signing this form, I (the Patient or Patient’s Legal Representative) acknowledge that I have been offered a copy or been informed of the location of the following Bayless Healthcare Group policies.*

• NOTICE OF PRIVACY PRACTICES (NPP) • PATIENT RIGHTS AND GRIEVANCE POLICY

• FINANCIAL POLICY • NOTICE OF HEALTH INFORMATION PRACTICES

I understand that BIH reserves the right to change the terms of its Notice provisions and that I can obtain a copy upon request at any BIH clinic/office.

ACC HEALTH PLANS HANDBOOKS AND WEBSITE ADDRESS- AHCCCS PATIENTS ONLY

By signing this form, I acknowledge that I have received the ACC Health Plans handout with web addresses and phone numbers.

NOTICE OF HEALTH INFORMATION EXCHANGE PRACTICES

Bayless participates in an electronic information service offered by The Network, a nonprofit 501(c)(3) non-

governmental organization operated by Arizona Health-e Connection (AzHeC). This service does not cost you anything

and can help your doctor and health care providers better coordinate your care by securely sharing your health

information. If you would like your doctor and other health care providers to electronically and securely share your

health information to better coordinate your care, YOU DO NOT NEED TO DO ANYTHING. If you would like to opt out,

you may do so at any time by completing an Opt Out Change Form, available at any clinic location or at

www.baylesshealthcare.com

*If you are completing this form prior to your scheduled appointment please note that all the policies listed can be made available to

you upon arrival to our office, or are accessible online at www.baylesshealthcare.com and www.baylesspediatrics.com.

Print Patient or Legal Guardian/Representative’s Name Relationship to Patient

Patient’s or Legal Guardian/Representative’s Signature Date

FOR OFFICE USE ONLY

☐ Check box if Patient or Legal Guardian/Representative is unwilling or unable to sign acknowledgement form and state the reason below.

This section is to be completed if no signature is obtained above. If it is not possible to obtain the patient’s acknowledgement, describe the good faith

efforts made to obtain the individual’s acknowledgement and the reason(s) why the acknowledgement was not obtained.

Reason:

BIH Staff Initials Date

APPOINTMENT NO SHOW POLICY AND ACKNOWLEDGEMENT FORM

Patient’s Name: Date of Birth:

PS-FRM004.00-A (10/18)

At Bayless Integrated Healthcare (BIH) quality of care is always the top priority and we sincerely value the

time of both our clients and staff. To ensure we are providing the best possible care, in a timely manner,

the following No Show policy is in effect for all Commercial and Self pay clients.

A client in need of a Medical, dietetic, Psychiatric and/or Counseling appointment will be scheduled for an

appointment at a time the client agrees they can attend. If for any reason the client is unable to keep the

scheduled appointment it is the responsibility of the Client, Parent, and/or Legal Guardian to call Bayless

staff, at least twenty-four (24) hours in advance, to cancel. If the Client fails to cancel their appointment

at least twenty-four (24) hours in advance, a $50 no show fee will be applied. This fee must be paid

prior to being seen for any Medical, Dietetic, Psychiatric and/or Counseling appointment. Note: All

AHCCCS patients are exempt from this fee. However, if any patient regardless of insurance has 3 no

show occurrences without 24-hour notice, the patient may be dismissed from the practice.

Your signature below acknowledges your understanding of BIH’s No Show Policy and your agreement to

the following:

1. Client will be offered an appointment time for which they agree they can attend.

2. Client will call twenty-four (24) hours in advance to cancel the appointment.

3. If a commercially insured or self-pay client fails to cancel their appointment at least 24 hours in

advance there will be a $50 No Show fee applied.

4. This fee is charged to the patient, not the insurance company, and is due at the time of the patient’s next

office visit.

5. If a Client has 3 no show occurrences (including cancels/reschedules an appointment without a 24-hour

notice), the patient may be dismissed from the practice

Patient or Legal Guardian/Representative’s Name Relationship to Patient

Patient’s or Legal Guardian/Representative’s Signature Date

RE-FRM006.00 (11/17)

Patient Code of Conduct

Patient’s Name: Date of Birth:

Bayless Integrated Healthcare will treat the patient with compassion in a safe and supportive environment, treat the

patient with respect and dignity, and inform the patient of conduct expectations while in our offices.

We, at Bayless Integrated Healthcare, believe that for the best possible outcomes for our patients’ overall healthcare,

that consistent participation is pivotal in receiving positive outcomes. In order to receive the best possible outcomes, it

is imperative that the patient participates consistently in his/her treatment plan.

I agree to the following while at Bayless Integrated Healthcare:

I agree to participate consistently with my treatment plan in order to receive the best possible outcomes.

I agree to not be destructive to persons, place, or property while at Bayless Integrated Healthcare. I will take

responsibility for my personal belongings and respect other people’s property. I understand that if I am

destructive to Bayless Integrated Healthcare property, I will be responsible for any cost associated with the

damage.

I agree to not harm myself or others while at Bayless Integrated Healthcare; any hitting, kicking; stomping; etc.

will not be tolerated.

I agree to not use profanity, inappropriate language, or yell or scream at myself or others while at Bayless

Integrated Healthcare.

I agree to not show up to my appointments under the influence of alcohol or any non-medically prescribed

substances (illicit drugs).

I have received a copy of the Patient Code of Conduct and understand it. Further, I understand that Bayless Integrated

Healthcare has the right to close my case file and recommend I receive services elsewhere in the event I do not comply

with the above expectations.

Print Patient or Legal Guardian/Representative’s Name Relationship to Patient

Patient’s or Legal Guardian/Representative’s Signature Date

Advance Directive Form Effective Date 06/15/13

Advance Directive Form PM Form 3.12.1

THIS FORM MUST BE COMPLETED AND PROMINENTLY DISPLAYED IN THE MEMBER MEDICAL RECORD

__________________________________________________________________________ Section I. Advance Directive Information Provided to Members (to be checked and initialed by the member) I have been provided written information about Advance Directive via the Member Handbook. __________________ _______ Member initials Date I have been provided a verbal explanation about Advance Directives __________________ _______ Member initials Date I have been provided the Advance Directives Resource sheet as a helpful tool in developing an advance directive __________________ _______

Member initials Date

Section II Advance Directives Development Date:____________________ (to be filled out by the Assigned Clinician) Member has developed an Advanced Directive Yes_______ No______ If No, stop here and let the member recipient know that assistance in developing an Advanced Directive is available If an Advanced Directive has been executed (developed) is it in the medical record Yes______ No______ If Advance Directive has been executed, but is not filed in the medical record, please check the applicable box below: _____ Member does not wish to have it filed in his/her medical record _____ Clinical Liaison/Case Manager has asked for a copy, but has not been provided one _____ Other_______________________________________________________________________________ To facilitate coordination of care: _____ Has a copy of an executed Advanced Directive or refusal been sent to the Member’s PCP?

Section III. Advance Directives Enactment/Execution Has the Advance Directive document ever been acted on Yes____ No_____ If Yes, have all appropriate parties been notified? ____ Yes (specify who)__________________________________________________________________ ____ No (describe why not)_______________________________________________________________

Effective Date 04/01/14

Advance Directives Resources

About Advance Directives

Federal regulations define an advance directive as a written instruction, such as a living will or durable power of attorney for health care, recognized under state law (whether statutory or as recognized by the courts of the state), relating to the individuals wishes regarding the provision of health care when the individual is incapacitated.

Advance Directives for Health and Mental Health Care

These are documents that the individual creates that appoint someone else to make health care or mental health care decisions in the event the individual becomes incapacitated or incapable of making treatment decisions. The instructions provided in the documents are followed should an individual become unable to express his or her wishes.

What to do with Advance Directives

Advance directives are documents signed by a competent person giving direction to health care providers about treatment choices in certain circumstances. By creating an advance directive, the individual remains in control of health care decisions since these wishes were written down in advance. If the individual is no longer able to make decisions, doctors and other health care providers are legally obligated to follow the patient’s wishes outlined in the advance directive.

Local Resources for Creating Advance Directives

Recovery Innovation of Arizona provides a peer support specialist who teaches mental health care power of attorney classes. Please contact:

Recovery Innovation of Arizona

2701 N. 16th Street, Suite 316 Phoenix, Arizona 85006 602-650-1212 or 866-481-5361

Web Sites Providing Advance Directive Information

Arizona Developmental Disabilities Planning Council; click on Resources & Links and go to

other resources for the Legal Options Guide The Arizona Secretary of State; click on Advance Directives A rizona Attorney General’s Office; click on Life Care Planning

t a Video, Advance Directive Documents and Instructions or Other Materials

Health Care Decisions 602-530-6900 or http://www.hov.org/health_care_decisions.aspx Arizona Attorney General’s Office at 602-542-1610 or http://www.azag.gov/life_care/

ques

Re

Mercy Maricopa Integrated Care is the Regional Behavioral Health Authority for Maricopa County, funds for services are provided through as contract with Arizona Department of Health Services/Division of Behavioral Health.

Community Based Crisis Contact Numbers (Aug 21, 2014) P a g e | 1

Community Based

Crisis Contact Numbers

MMIC Community Crisis Hotline 1-800-631-1314 (Child Services)

1-800-564-5465/602-222-9444 (Adult Services)

Human Rights Advocate 602-364-4585 (business hours)

1-800-867-5808 or 602-542-1025 ADHS (After Hours #)

National Domestic Violence Hotline (Bilingual) 1-800-799-7233

Shelter Hotline 211 (YES this is correct, from an outside line dial 211 for further assistance)

Arizona Protective Services now called Arizona Dept of Economic Security (DES) 1-888-767-2445 (Child Abuse Hotline)

1-877-767-2385 (Adult Abuse Hotline)

www.azdes.gov/daas/aps/

Connection AZ Urgent Psych Adult Care (24hour services) 602-416-7600

1201 S. 7th Ave., #150, Phoenix AZ 85007

St Luke’s Behavior Health Hospital (Children, Adolescents, and Adults) 602-251-8535

1800 E Van Buren, Phoenix AZ 85008

Banner Psychiatric Center (24hours Walk-In) 480-448-7616 (Adolescents)

480-448-7600 (Adults)

7575 E. Earll Dr, Scottsdale AZ 85251

Phoenix Children Hospital (Children 12yo and under and under 140lb) 602-546-5515

1919 E Thomas Rd, Phoenix AZ 85016

Aurora Behavior Health Hospital (Adolescents 13yo and older/Adults) 480-345-5420

For Tempe and Glendale AZ locations

ACC Health Plans Web Addresses and Phone Numbers

ACC Health Plan Name

Website

Phone #

Care 1st Health Plan

www.care1staz.com

1-866-560-4042

Steward Health Choice Arizona

www.StewardHealthChoiceAZ.com

1-800-322-8670

Magellan Complete Care

www.mccofaz.com

1-800-424-5891

Mercy Care

www.mercycareaz.org

1-800-624-3879

Banner-University Family Care

www.bannerufc.com/acc

1-800-582-8686

United Healthcare Community Plan

https://www.uhccommunityplan.com

1-800-348-4058

Arizona Complete Health-Complete Care Plan

www.azcompletehealth.com/completecare

1-888-788-4408