CPSA PM Form 3.10.4
Waiver of 3-day
SMI Eligibility Determination
If you have trouble reading this notice because the letters are too small or the words are hard to read, please call CPSA at (800) 7719889, Option 2 or (520) 318-6946 and someone will help you. This form is available in other formats and languages if you need it.
Si usted tiene problemas leyendo ésta carta por que las letras son muy pequeñas o las palabras son difíciles de leer, por favor llame a
nuestras oficinas al (800) 771-9889 opción 2 o al (520) 318-6946 y alguien le ayudará. Esta carta está disponible en otros idiomas y
formatos si es que lo necesita.
Member Name:
DOB:
CIS ID:
AHCCCS ID:
/
/
(N/A if not enrolled)
Additional Time Needed
It is the goal of the Community Partnership of Southern Arizona (CPSA) or its designees to make a correct decision regarding your
eligibility for the program for Persons with Serious Mental Illness (SMI Program). We have identified that additional time is needed to
complete the determination for one of the following reasons:
We require additional time to request and obtain supplementary documentation, including, but not limited to, current and/or past
medical records or to perform or obtain any necessary psychiatric or psychological evaluations. We will issue the decision within 20
days.
By initialing here, you are in agreement we can take up to 20 days to make the determination.
New Determination Due Date: /
We have been unable to meet with you to make this determination. We will issue the decision within 20 days.
/
By initialing here, you are in agreement we can take up to 20 days to make the determination.
New Determination Due Date: / /
We require additional time to make the determination because you have indicated you are using substances (alcohol and/or other
drugs). For us to make a correct decision regarding your determination, we would need for you to not use substances for 90 days to
establish a qualifying mental health diagnosis.
By initialing here, you are in agreement we can take up to 90 days to make the determination and that you will not
use alcohold or other drugs during that time period so the determination can be made.
New Determination Due Date: / /
If you are not in agreement with any of the reasons above, please respond to the areas below:
By initialing here, you are reqesting the decision be made within 20 days for reasons other than those listed above.
OR
By initialing here, you are declining the request for more time and request your SMI Program eligibility be determined
in 3 business days using the information currently available.
Authorization
The above options have been fully explained to me so that I can make an informed decision about my care.
Member:
/
Name (print):
Signature
/
Date
Guardian (if applicable)
/
Name (print):
Signature
/
Date
Evaluator
/
Name (print):
Title and Credentials:
Signature
/
Date
3.10.4 – Page 1 of 1
Last Revised: 05/15/2013
Effective Date: 01/01/2015