2024 Healthcare Network Employee Questionnaire (HNEQ) Employer Attestation Form

2024 Healthcare Network Employee Questionnaire (HNEQ) Employer Attestation Form
Please read the below in its entirety and note that selecting the links below will navigate away from this submission and will not save your current fields. You will be emailed a copy of your submission with a link to this PDF; however, you can also select the ellipsis (three dots) on the upper right of the PDF window below to print.
Organization Attestation for HNEQ Compliance
Organization Name*, an organization contracted as AHCCCS Provider Type(s) and line(s) of business as identified below, attest that our organization shall meet the MCO’s workforce data collection participation requirements.
AHCCCS Provider Type(s) (please check all that apply):*

A3 Community Service AgencyA6 Rural Substance Abuse Transitional AgencyA7 RespiteB1 Level I Residential Treatment Center – Secure (IMD)B2 Level I Residential Treatment Center – NonSecure (non-IMD)B3 Level I Residential Treatment Center – NonSecure (IMD)B7 Crisis Services ProviderB8 Behavioral Health Residential FacilityC2 Federally Qualified Health Centers (FQHCs)- *see HP Provider ManualIC Integrated Clinics2 Hospital7 Dentist8 MD Physician8 OBGYN13 Occupational Therapist14 Physical Therapist15 Speech/Hearing Therapist18 Physician Assistant19 Registered Nurse Practitioner22 Nursing Homes23 Home Health Agencies24 Personal Care Attendant27 Adult Day Health29 Rural Health Clinics (RHCs)31 DO Physiciain Ostheopath - Cardiologist36 Assisted Living Homes37 Homemaker39 Habilitation Provider40 Attendant Care49 Assisted Living Center53 Supervisory Care Homes77 Behavioral Health Outpatient Clinic78 Level I Residential Treatment Center – SecureA5 Behavioral Health Therapeutic HomeBC Board Certified Behavioral Analyst85 Licensed Clinical Social Worker (LCSW)86 Licensed Marriage & Family Therapist (LMFT)87 Licensed Professional Counselor (LPC)A4 Licensed Independent Substance Abuse Counselor (LISAC)B5 Sub Acute Facility (1-16 Beds)
Contracted Health Plans (please check all that apply):*

Arizona Complete HealthBanner-University Family CareBCBS - Health Choice ArizonaCare1st Health PlanDivision of Developmental DisabilitiesMercy CareMolina Health CareUnitedHealthcare Community Plan
Line of Business (please check all that apply)*

ACCACC-RBHAALTCSDDDCS-CHP
Name of Responsible Party*

First NameLast Name
Title of Responsible Party*
Contact Phone Number*
Please enter a valid phone number.
Contact Email*
example@example.com
Date of Attestation*

MonthDayYear
Date
Signature Attestation*

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2024 Healthcare Network Employee Questionnaire (HNEQ) Employer Attestation Form

Organization Attestation for HNEQ Compliance