HIPAA Privacy Manual

Arizona Department of Health Services
Division of Behavioral Health Services

HIPAA Privacy Manual

Version 1.0
April 14, 2003

Arizona Department of Health Services
Division of Behavioral Health Services
HIPAA Privacy Manual

Table of Contents
Page No

SECTION 001:

HIPAA Privacy Requirements...............................................5

SECTION 002:

Administrative and General Requirements for the
Implementation of HIPAA .....................................................6

SECTION 003:

Minimum Necessary Standard .............................................9

SECTION 004:

Enrolled Persons ' Rights Related to Protected
Health Information...............................................................12
SECTION 005:

Provision of Privacy Notice ................................................17

SECTION 006:

Complaint/Grievance Process for Alleged Violations of Rights Relating to Protected Health Information .........18

SECTION 007:

Uses or Disclosure of Protected Health Information
Permitted Without Authorization........................................20

SECTION 008:

Use or Disclosure of Protected Health Information
Where Authorization, Agreement or Opportunity To
Object Is Required...............................................................28

SECTION 009:

Disclosure of Protected Health Information for
Research Purposes .............................................................33

SECTION 010:

Accounting for Disclosures of Protected Health
Information...........................................................................35

SECTION 011:

Definitions............................................................................38

SECTION 012:

Appendices ..........................................................................41

APPENDIX A:
APPENDIX B:
APPENDIX C:
APPENDIX D:
APPENDIX E:
APPENDIX F:
APPENDIX G:
APPENDIX H:

ADHS/DBHS WORKFORCE TRAINING MATERIALS ....................42
MINIMUM NECESSARY CRITERIA CHECKLIST ..............................44
ADHS/DBHS NOTICE OF PRIVACY PRACTICES .........................46
ADHS/DBHS DESIGNATED RECORD SET .................................57
REQUEST FOR RESTRICTIONS ON USE OR DISCLOSURE OF PHI 167
REQUEST FOR CONFIDENTIAL COMMUNICATIONS .....................174
REQUEST TO AMEND PROTECTED HEALTH INFORMATION .........177
COMPLAINT REGARDING VIOLATION OF PRIVACY OF PROTECTED
HEALTH INFORMATION FORM ..................................................185

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APPENDIX I:
APPENDIX J:
APPENDIX K:
APPENDIX L:

AUTHORIZATION FOR USE OR DISCLOSURE OF PROTECTED HEALTH
INFORMATION ........................................................................188
ACCOUNTING OF DISCLOSURES ..............................................193
RECORD OF DISCLOSURES FOR PURPOSES OF PUBLIC
RESPONSIBILITY ....................................................................197
ARIZONA BEHAVIORAL HEALTH PREEMPTION GUIDE ................200

CURRENTLY

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HIPAA Privacy Manual

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SECTION 001: HIPAA Privacy Requirements
REFERENCES:

Directive to Comply with the Health Insurance Portability and
Accountability Act of 1996[HIPAA]; 42 U.S.C. §§ 1320d-1329d-8

SCOPE:

All Arizona Department of Health Services/Division of Behavioral Health
Services Workforce Members (i.e., employees, volunteers and trainees)

EFFECTIVE DATE:

April 14, 2003

A. PURPOSE:
The purpose of this Privacy Manual shall be to establish requirements for ADHS/DBHS’ compliance as a
Health Plan with the Health Insurance Portability and Accountability Act of 1996 42 U.S.C. §§ 1320d-1329d8, and regulations promulgated there under, 45 CFR Parts 160 and 164 (HIPAA). As a Health Plan,
ADHS/DBHS pays for behavioral health care, including Medicaid reiumbursable services under Title XIX of the Act, 42 U.S.C. 1396, et seq, and approved State child behavioral health services under Title XXI of the
Act.
B. DIRECTIVE:
ADHS/DBHS workforce members are directed to follow all applicable requirements found in the
ADHS/DBHS HIPAA Privacy Manual and the HIPAA Rule.
C. DISCIPLINARY ACTION:
Failure to comply with the Privacy Rule and its reference documents may result in disciplinary action as defined in ADHS agency level one policy and procedure OHR009 Discipline, effective 04/02/02, and its amendments. Leslie Schwalbe
Deputy Director

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SECTION 002:
Administrative and General Requirements for the
Implementation of HIPAA
A. PURPOSE:
To issue instructions to all ADHS/DBHS workforce members regarding ADHS/DBHS obligations relating to the implementation of the Health Insurance Portability and Accountability Act (HIPAA), 42 U.S.C. §§ 1320d1329d-8, and regulations promulgated there under, 45 CFR Parts 160 and 164.
B. ADMINISTRATIVE REQUIREMENTS:
Personnel Designations:
Privacy Officer: ADHS designates the ADHS HIPAA Project Manager as the Agency Privacy
Officer, responsible for the development and implementation of ADHS requirements relating to the safeguarding of protected health information.
Contact Office For HIPAA Privacy Complaints: ADHS/DBHS designates the Manager of
Grievance and Appeals, phone number- 602.381.8999, as responsible for receiving enrolled persons’ complaints relating to HIPAA privacy rights and rights to access the enrolled person’s designated record set and Protected Health Information. Enrolled persons may also contact the
ADHS Agency Privacy Officer, phone number [phone] to file a HIPAA privacy complaint.
Contact Office for HIPAA Privacy Practices Content: ADHS/DBHS designates the HIPAA
Analyst, phone number [phone], as responsible for providing information about the privacy practices of ADHS/DBHS and receiving requests for: restricting the use or disclosure of enrolled person’s Protected Health Information, confidential communications of protected health related information, amendment of the enrolled person’s designated record set, or an accounting of disclosures made of enrolled persons’ Protected Health Information.
Training Requirements: ADHS/DBHS has documented the following training actions:
On or before the effective date of the HIPAA privacy regulations [04/14/03], all ADHS/DBHS workforce members received training on applicable requirements relating to Protected Health
Information as necessary and appropriate for such persons to carry out their functions within
ADHS/DBHS.
Each new workforce member receives the training as described above within a reasonable time after joining the workforce.
Each workforce member whose functions are impacted by a material change in the requirements relating to Protected Health Information, or by a change in position or job description, receives the training as described above within a reasonable time after the change becomes effective.
Please see Appendix A: ADHS/DBHS Workforce Training Materials that contains the training slides presented prior to 04/14/03 and a sample of the ADHS/DBHS Employee Confidentiality Statement signed by each ADHS/DBHS workforce member.
Disciplinary Actions: In accordance with ADHS Level One policy and procedure OHR009 Discipline, effective 04/02/02, and its amendments, ADHS/DBHS will apply disciplinary actions, as appropriate, to members of its workforce who fail to comply with the ADHS/DBHS HIPAA Privacy Manual requirements or who fail to comply with the HIPAA Privacy Rule.
Complaint Process: ADHS/DBHS has a complaint process for enrolled persons to make complaints about the ADHS/DBHS HIPAA Privacy requirements or ADHS/DBHS’ compliance with those requirements, and documents all complaints received and the disposition of each complaint. ADHS/DBHS mitigates, to the extent practicable, any harmful effects of unauthorized uses or disclosures of Protected Health Information made by ADHS/DBHS workforce members.
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Prohibition on Intimidating or Retaliatory Acts: Neither ADHS/DBHS nor any workforce member shall intimidate, threaten, coerce, discriminate against, or take other retaliatory action against any enrolled person for the exercise of his/her rights or participation in any process relating to HIPAA Privacy compliance, or against any person for filing a complaint with the Secretary of the U.S.
Department of Health and Human
Services, participating in a HIPAA related investigation, compliance review, proceeding or hearing, or engaging in reasonable opposition to any act or practice that the person in good faith believes to be unlawful under HIPAA regulations as long as the action does not involve disclosure of Protected Health Information in violation of the regulations.
Prohibition on Waiver of Rights: Neither ADHS/DBHS nor any workforce member shall require enrolled persons to waive any of their rights under HIPAA as a condition of treatment, payment, operations, enrollment in the health plan or eligibility for Non Title XIX benefits.
Documentation Requirements: ADHS/DBHS maintains the HIPAA Privacy Manual in written or electronic form, and maintains written or electronic copies of all communications, actions, activities or designations as are required to be documented herein, or otherwise under the HIPAA regulations, for a period of six (6) years from the later of the date of creation or the last effective date or such longer period that may be required under state or other federal law.
Privacy Security Requirements: When sending or receiving Protected Health Information,
ADHS/DBHS workforce members will only use encrypted files. Internal encryption will be accomplished through the use of software installed by ADHS Information Technology Services and meeting the requirements for securing
Protected Health Information. When Protected Health Information is received by the ADHS workforce or disclosed to covered entities, business associates, as permitted under the HIPAA rule, by law, or pursuant to and in compliance with a valid authorization, the Protected Health Information will be encrypted before sending or receiving it through the use of software meeting the requirements for securing Protected Health
Information.
C. GENERAL REQUIREMENTS:
Notice of Privacy Practices: In general, Protected Health Information shall not be used or disclosed except as permitted or required by law. Enrolled persons served through the ADHS/DBHS behavioral health system of care are given a Notice of Privacy Practices by the Tribal/Regional Behavioral Health Authority
(T/RBHA) in which the person is enrolled. The T/RBHA Notice of Privacy Practices outlines the uses and disclosures of Protected Health Information that may be made, and notifies the enrolled person of their rights and the T/RBHA’s legal duties with respect to Protected Health Information. The ADHS/DBHS performed a one-time distribution of the ADHS/DBHS Notice of Privacy Practices to persons enrolled in the ADHS/DBHS
Client Information System (CIS). ADHS/DBHS posts the ADHS/DBHS Notice of Privacy Practices on the
ADHS/DBHS web site for ease of public access.
Business Associates: ADHS/DBHS Business Associates perform or assist in the performance of functions or activities involving the use or disclosure of protected health information on behalf of ADHS/DBHS including claims processing or administration; data analysis, processing or administration; utilization review; quality assurance; billing; practice management; or repricing; or provide legal; actuarial; accounting; consulting; data aggregation; management; administrative; or financial services where the provision involves the disclosure of protected health information.
Disclosure to the Enrolled Person: Protected Health Information is disclosed to the enrolled person to carry out treatment, payment or operations activities within specified limits, pursuant to and in compliance with a current and valid Authorization, in keeping with a Business Associate arrangement, or as otherwise provided for in the HIPAA privacy regulations. Please refer to Section 007 Use or Disclosure of Protected
Health Information Permitted Without Authorization for further information regarding disclosure to the enrolled person.
Minimum Necessary: When using or disclosing Protected Health Information, or when requesting
Protected Health Information from another covered entity, reasonable efforts are be made to limit the
Protected Health Information used or disclosed to the minimum amount of information necessary to accomplish the purpose of the use or disclosure.
Personal Representative: A person acting in the role of Personal Representative must be treated as the enrolled person regarding access to relevant Protected Health Information unless:
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1.

The enrolled person is a minor and
a. is authorized to give lawful consent, or
b. may obtain the health care without consent of the Personal Representative or
c. the minor has not requested that the person be treated as a Personal Representative.

or
2.

There is a reasonable basis to believe that the enrolled person
a. has been or may be subjected to domestic violence, abuse or neglect by the Personal
Representative, or
b. that treating the designated person as a Personal Representative could endanger the enrolled person, and, in the exercise of professional judgment, it is determined not to be in the best interests of the enrolled person to treat the designated person as a
Personal Representative.

Agreed Upon Restrictions: An enrolled person has a right to request a restriction on any uses or disclosures of his/her Protected Health Information, though ADHS/DBHS need not agree to the requested restriction, and cannot agree to a restriction relating to disclosures required under law or disclosures to the
U. S. Secretary of Health and Human Services for HIPAA enforcement purposes.
Confidential Communications: An enrolled person has a right to request to receive communications of
Protected Health Information by alternative means or at alternative locations, and reasonable requests shall be accommodated.
Accounting for Disclosures: An enrolled person has a right to an accounting of disclosures of his/her
Protected Health Information for up to a six (6) year period.
De-identified Protected Health Information: ADHS/DBHS may use Protected Health Information to create information that is not individually identifiable for its own use or for disclosure to a business associate. If individually identifiable health information is "de-identified" it is no longer treated as Protected Health
Information. Please refer to Section 011 Definitions for a definition of the term “de-identified”. Disclosure of a code or other means of record identification designed to enable coded or otherwise de-identified information to be re-identified constitutes disclosure of Protected Health Information.
ADHS/DBHS may assign a code or other means of record identification to allow de-identified information to be re-identified by ADHS/DBHS provided that:
a.

the code or other means of record identification is not derived from or related to information about the individual and is not otherwise capable of being translated so as to identify the individual; b.

ADHS/DBHS does not use or disclose the code or other means of record identification for any other purpose, and does not disclose the mechanism for re-identification; and

c.

If de-identified information is re-identified, ADHS/DBHS may use or disclose such re-identified information subject to the requirements for uses and disclosures of Protected Health
Information.

Complaint Process: ADHS/DBHS has a process for enrolled persons to make complaints about the
ADHS/DBHS HIPAA Privacy Manual contents or ADHS/DBHS or its workforce members’ compliance with the requirements as described in this Manual.
Documentation: ADHS/DBHS maintains written or electronic copies of the HIPAA Privacy Manual and communications or actions required to be documented under this manual for a period of six (6) years.

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SECTION 003:

Minimum Necessary Standard

A. PURPOSE:
To issue instructions to all ADHS/DBHS workforce members regarding ADHS/DBHS obligations relating to the HIPAA requirement to use, disclose, or request only the minimum amount of Protected Health
Information necessary to accomplish the intended purpose of the use, disclosure or request.
B. MINIMUM NECESSARY REQUIREMENTS:
ADHS/DBHS and its workforce members make reasonable efforts to limit individually identifiable health information to that which is minimally necessary to accomplish the intended purpose for the use, disclosure or request.
The minimum necessary requirement applies to:
a.
b.
c.

uses or disclosures requiring the enrolled person to have an opportunity to agree or object; uses or disclosures that are permitted without authorization, except for those required by law or otherwise specified in the ADHS/DBHS HIPAA Privacy Manual; uses or disclosures to business associates.

The minimum necessary requirement does not apply to:
a.
b.
c.
d.
e.
f.
g.

disclosures to the enrolled person: disclosures made pursuant to and in compliance with a valid authorization; disclosures to or requests by healthcare providers for treatment; disclosures required for compliance with the standardized HIPAA transactions; uses or disclosures pursuant to an agreement between ADHS/DBHS and the enrolled person for a restriction on the use or disclosure of Protected Health Information; disclosures made to the U.S. Department of Health and Human Services pursuant to a privacy investigation; or disclosures otherwise required by the HIPAA regulations or other laws.

As permitted by HIPAA, within the ADHS/DBHS system of behavioral health care service delivery, the
Minimum Necessary standard does not apply to routine uses or disclosures of Protected Health Information for treatment, payment and operations including, but not limited to, uses or disclosures related to the following functions as described in the ADHS/DBHS RBHA Contracts and Tribal RBHA InterGovernmental
Agreements, the ADHS/DBHS Policy and Procedure Manual, the ADHS/DBHS Provider Template, or
Directives, Performance Improvement Protocols, or documents that provide technical assistance, advice, direction, or instruction to the Tribal andRegional Behavioral Health Authorities and their subcontracted health care providers.
Uses or Disclosures for Treatment Purposes:
Referral
Screening and Triage
Enrollment Procedures
Engagement
Disenrollment Procedures
Initial Assessments
Service Delivery
Crisis Services
Substance Abuse Services
Outreach
Coordination of Care
Vocational Services
Prevention Services
Laboratory Testing Services
HB2003 Services
Other Treatment relevant information

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Uses or Disclosures Relating to Payment Purposes:
Co-Payments and Sliding Fee Schedule
Performance Bond or Bond Substitute
Amount of Performance Bond
ADHS Claims to Performance Bond Proceeds Upon Default
Encounter Submission Requirements
Data Validation Study
Information System
Provider Billing
Sanctions and Corrective Actions
Subcontracts
Management Services Subcontractors and Corporate Cost Allocation Plans
Management Services Subcontractor Audits
Coordination of Benefits and Third Party Liability
Medicare Services and Cost Sharing
Financial Reporting and Viablity Measures
Advancement of Funds by the Contractor
Financial Agreed-Upon Procedures
Financial Disclosure to the Community
Section D Contract Funding (and its subsections)
Attachment C Management Services Subcontractor Statement
Attachment E Capitation Rates
Other Payment relevant information
Uses or Disclosures Related to Health Care Operations:
Appointment Standards
Behavioral Health Records
Community Advisory Board
Quality Management
Utilization Management
Provider Network Requirements
Provider Network Management
Provider Registration
Provider Network Status Reports
Member Information Materials and Handbook
Notice of Denial, Reduction, Suspension, Termination of Services
Written Policies, Procedures and Job Descriptions
Staff Requirements/Support Services
Training
Memorandum of Understanding for Provision of Services to Children
Grants
Provider Manual
Information System
Grievance/Appeal/Request for Hearing Standards
Transition from Current RBHA to the Contractor
Pending Legislative Issues
Litigation
Annual Administrative Review
Periodic Report Requirements
Section E Contract Clauses and its subsections
Attachment A Contract Provisions
Attachment B Minimum Network Standards
Attachment D Periodic Report Requirements for the ADHS
Other Health Care Operations relevant information
ADHS/DBHS makes reasonable efforts to limit each workforce member’s access to only the Protected
Health Information needed to carry out their duties. These efforts ADHS/DBHS internal staff to staff use and disclosure of Protected Health Information.
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ADHS/DBHS workforce members who provide disclosures on a routine and recurring basis may rely on a requested disclosure as the minimum necessary to accomplish the stated purpose when:
a.
b.

c.
d.

information is requested by another covered entity; information is requested by a professional who is a member of the ADHS/DBHS workforce or is a business associate of ADHS/DBHS for the purpose of providing professional services, provided the professional states that the information is the minimum necessary for the stated purpose; making disclosures to public officials if the public official states that the information requested is the minimum necessary for the stated purpose; or documenting research activities.

Non-routine disclosures may include, but are not limited to, disclosure to accrediting bodies, insurance carriers, research entities, or funeral homes.
For non-routine disclosures of Protection Health Information, i.e., disclosures other than those permitted without authorization or pursuant to and in compliance with a valid authorization, ADHS/DBHS will determine the minimum necessary information to be disclosed through the application of the following criteria:
•
•
•
•
•
•

Verification of the identify and authority of the requesting party;
Specific purpose of the request;
Specific Protected Health Information requested;
Whether a summary of the Protected Health Information requested will achieve the intended purpose;
Whether de-identified or aggregate information will achieve the intended purpose; and
Whether the requesting party has attempted, or has, obtained an authorization from the enrolled person.

ADHS/DBHS may rely on any of the following to verify the identity of a public official or person acting on the public official’s behalf:
a.
b.
c.
d.
e.

if the request is made in person, an agency identification badge, other official credentials, or other proof of government status; if the request is made in writing, the request is on appropriate government letterhead; if the disclosure is to a person acting on behalf of the public health official, a written statement on appropriate government letterhead that the person is acting under the government’s authority or similar evidence that establishes the person’s identify; a written statement on appropriate government letterhead of the legal authority under which the information is requested, or if impracticable, an oral statement; or if the request is made pursuant to legal process, warrant, subpoena, order or other legal process, it is presumed to constitute legal authority.

Use or disclosure of the entire behavioral health medical record should not be made unless use or disclosure of the entire medical record is specifically justified as the amount of information reasonably necessary to accomplish the purpose of the use or disclosure.
Please see Appendix B for the Minimum Necessary Criteria Checklist form.

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SECTION 004:

Enrolled Persons ' Rights Related to Protected Health
Information

A. PURPOSE:
To issue instructions to all ADHS/DBHS workforce members regarding ADHS/DBHS’ obligations relating to enrolled persons’ rights relating to access to and use/disclosure of their Protected Health Information.
B. REQUIREMENTS FOR ENROLLED PERSON’S RIGHTS:
1. Right to Access Protected Health Information: Enrolled persons have the right to access and obtain a copy of their Protected Health Information or any other information in the designated record set. Please see
Appendix D: ADHS/DBHS Designated Record Set for a listing of the data elements and valid values constituting the ADHS/DBHS record set. The form to be used to request access to the record set content is located in Appendix C: Request to Access Protected Health Information.
Denial of Access without a right of review: Access to Protected Health Information and any information in the designated record set may be denied when:
a.
b.
c.

Information was compiled in anticipation of litigation;
Information was collected in the course of research that includes treatment of the enrolled person and the enrolled person agreed to a suspension of the right of access during the research period; or In accordance with the Clinical Laboratory Improvements Amendments of 1988 (CLIA) or the
Privacy Act (5 USC 552a), when applicable.

Denial of Access with a right of review: Access to Protected Health Information and any information in the designated record set may be denied, though denial is subject to review where:
a.
b.

c.

Access is determined by a licensed professional to be likely to endanger life or physical safety of the enrolled person or another person; and such determination is documented,
The protected behavioral health care information makes reference to another person (unless such other person is a health care provider) and a licensed health care professional has determined, in the exercise of professional judgement, that the provision of access is reasonably likely to cause substantial harm to such other person; or
A Personal Representative requests access and a licensed professional determines that such access is reasonably likely to cause substantial harm to the enrolled person or another person.

Right of Review: If the basis for denial of access gives a right of review, the enrolled person has a right to have the denial reviewed by another licensed professional who did not participate in the original denial decision. Such review must be completed within a reasonable period of time, and the
ADHS/DBHS must promptly: (i) provide the enrolled person with notice of the reviewer 's decision, and
(ii) comply with the determination to provide or deny access.
To request a review of the denial of access to Protected Health Information, please see the Request for
Review of Denial of Request for Access to Protected Health Information Notice located in Appendix C.
ADHS/DBHS will respond in writing to the review request using the Notice of Outcome for Denial of
Access Review form located in Appendix C.
Timely Review: A request for access to Protected Health Information will be acted on no later than thirty (30) days after receipt unless the time period is extended as permitted below:
a.
b.

If the information to be accessed is not maintained or accessible on-site, ADHS/DBHS acts on the request no later than sixty (60) days after receipt, or
If ADHS/DBHS is unable to act on the request for access within the applicable 30 or 60 day period, it may extend the time for response by no more than thirty (30) days.

ADHS/DBHS will provide a response to the request for access using the Response to Request for
Access to Protected Health Information in Appendix C. If the time period for response is extended,
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ADHS/DBHS will provide the requester with the Notice of Extension for Provisions of Access to
Protected Health Information form located in Appendix C.
Provision of Access: ADHS/DBHS provides the enrolled person with access to the information in the form or format requested if it is readily producible or in a readable hard copy or other form or format as mutually agreed to, either by arranging for a convenient time and place for inspection and copying, or mailing the information at the enrolled person 's request. If the information is maintained in more than one place, the information will only be produced once in response to a current request for access.
ADHS/DBHS may provide a summary of the Protected Health Information in lieu of providing access, or may provide an explanation of the Protected Health Information to which access is provided if the enrolled person agrees, in advance.
ADHS/DBHS may charge a reasonable, cost-based fee for the costs of copying Protected Health
Information, including labor, postage and preparation cost of an explanation or summary. Upon request for a copy of the Protected Health Information, one free copy is furnished during a 12 month period of time.
Denial of Access: ADHS/DBHS provides a timely, written denial of access to the enrolled person, written in plain language, explaining the basis for the denial, and any applicable right of review, and describes how the enrolled person may complain to the Manager of Grievance and Appeals at (602)
381-8999 or the U.S. Secretary of Health and Human Services.
To the extent possible, the enrolled person must be given access to any of their Protected Health
Information in the designated record set requested after excluding the Protected Health Information for which ADHS/DBHS has grounds for denying access.
If ADHS/DBHS does not maintain the Protected Health Information for which access has been requested, but knows where it is maintained, ADHS/DBHS must inform the enrolled person where to direct their request for access.
If ADHS/DBHS denies the request for access to Protected Health Information, the requester will be provided the Notice of Denial of Request for Access to Protected Health Information form located in
Appendix C.
Documentation: ADHS/DBHS documents and retains for six years, from the date of its creation, the designated record sets subject to access. Requests for access to Protected Health Information contained in the designated record sets should be directed to:
Prior to July 1, 2003
Arizona Department of Health Services
Division of Behavioral Health Services
HIPAA Analyst
2122 East Highland Avenue, Suite 100
Phoenix Arizona 85016
Phone: [phone]

On or After July 1, 2003
Arizona Department of Health Services
Division of Behavioral Health Services
HIPAA Analyst th 150 N.
18 Avenue
Phoenix Arizona 85007
Phone: [phone]

2. Right To Request Restrictions On Uses or Disclosures Of Protected Health Information, And
To Request Confidential Communications:
The ADHS/DBHS HIPAA Analyst is designated as the person or position title responsible for receiving requests to restrict the use or disclosure of enrolled person’s Protected Health Information and requests for confidential communications of protected health related information.
Requests for Restrictions on Uses or Disclosures: ADHS/DBHS permits an enrolled person to request that ADHS/DBHS restrict uses and disclosures of Protected Health Information made for treatment, payment or operations or disclosures to family or others involved in the enrolled person 's care, though ADHS/DBHS does not have to agree to the restriction requested.
If ADHS/DBHS agrees to the requested restriction(s), ADHS/DBHS must document the agreed upon restriction in writing, and abide by the restriction unless the enrolled person is in need of emergency treatment, the information is needed for the treatment, and the disclosure is to another
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ADHS/DBHS cannot agree to a restriction that prevents uses or disclosures required or otherwise permitted under the HIPAA rule.
ADHS/DBHS may terminate an agreed upon restriction if the enrolled person so agrees, as documented in writing, or ADHS/DBHS informs the enrolled person and the termination is only effective as to Protected Health Information created or received after such notice.
To request a restriction on the use or disclosure of Protected Health Information please use the form located in Appendix E: Request for the Restrictions on Use or Disclosure of Protected Health
Information. ADHS/DBHS will respond to the requester using the Response to Request for
Restriction on Use or Disclosure or Protected Health Information also located in Appendix E. If a termination of the restriction occurs, the involved enrolled person will be notified with the
Termination of Restriction on Use or Disclosure of Protected Health Information form located in
Appendix E.
Requests for Confidential Communications: ADHS/DBHS permits enrolled persons to request to receive communications of Protected Health Information by alternative means or at alternative locations, and must accommodate all reasonable requests.
The enrolled person should submit the Request for Confidential Communications in Appendix F when requesting confidential communication of their Protected Health Information. ADHS/DBHS will provide the enrolled person with the Response for Request for Confidential Communications form in response to the request. This form is also located in Appendix F.
3. Right To Request Amendment Of Protected Health Information or Other Information in the
Designated Record Set:
The ADHS/DBHS HIPAA Analyst is designated as the person/position title responsible for receiving requests for amendment of the enrolled person’s Protected Health Information or other information in the designated record set.
Requests for Amendment of Protected Health Information: An enrolled person has the right to have ADHS/DBHS amend their Protected Health Information or other information in the designated record set for as long as ADHS/DBHS maintains the information.
ADHS/DBHS must act on the request within sixty (60) days of receipt, or within ninety (90) days if
ADHS/DBHS notifies the enrolled person within the first 60 days of the reasons for delay and the date by which action will be taken. Please see Appendix G for the Request To Amend Protected
Health Information form to be used when submitting a request.
Accepting the Amendment: If ADHS/DBHS accepts the amendment, in whole or in part,
ADHS/DBHS shall:
a.
Make the amendment by, at minimum, identifying the affected data elements and valid values in the Protected Health Information or other information in the designated record set, and appending or otherwise providing a link to the location of the amendment; b.

Timely inform the enrolled person that the amendment is accepted,

c.

Notify relevant persons or entities with a need to know; and

d.

Make reasonable efforts to inform and timely provide the amendment to those persons and others, including business associates, that ADHS/DBHS knows:
i. To have the affected Protected Health Information and ii. May have relied, or be foreseen to rely, on that information to the detriment of the enrolled person.

Denying the Amendment:
ADHS/DBHS may deny the request for amendment of the Protected Health Information or other
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was not created by ADHS/DBHS (unless the originator of the information is no longer available to act on the request);

b.

is not part of the designated record set;

c.

would not be available for inspection; or

d.

is accurate and complete.

If ADHS/DBHS denies the amendment to the Protected Health Information and other information in the designated record set, in whole or in part, ADHS/DBHS will:
a.

Provide the enrolled person with a timely denial, written in plain language and including:
a. the basis for denial;
b. notice of the enrolled person 's right to submit a written statement of disagreement,
c. instructions on how to file the statement of disagreement, and
d. a description of how the enrolled person may complain about the decision to
ADHS/DBHS or to the U. S. Secretary of Health and Human Services;

b.

Provide a copy of any rebuttal prepared to the enrolled person;

c.

As appropriate, identify the part of the Protected Health Information and other information in the designated record set, subject to the disputed amendment and append or otherwise link the request, the denial, and any statement of disagreement or rebuttal to the record;

d.

For future disclosures of Protected Health Information and other information in the designated record set, include any statement of disagreement or, in response to the enrolled person 's request, the amendment request and the denial. . Documentation of the disagreement or request to include the amendment request and denial will be documented on the Statement of Disagreement/Request to Include Amendment Request and Denial with Future Disclosure form located in Appendix G.

e.

If standard transaction format does not permit the appending of the additional information, it must be transmitted separately to the recipient of the standard transaction.

Please see Appendix G for the Response to Request to Amend Protected Health Information form used by
ADHS/DBHS when responding with an acceptance or denial of the request to amend.
If ADHS/DBHS is informed by another covered entity about an amendment to the record, ADHS/DBHS must amend the information in its record by, at a minimum, identifying the affected records and appending or otherwise providing a link to the location of the amendment.
ADHS/DBHS must document the titles of the persons or offices responsible for receiving and processing requests for amendments.
4. Right To An Accounting Of Disclosures: An enrolled person has a right to receive an accounting of disclosures of his/her Protected Health Information or other information in the designated record set. The following disclosures do not have to be included in the accounting:
a.

Disclosures for treatment, payment or healthcare operations;

b.

Disclosures to the enrolled person;

c.

Disclosures occurring with enrolled person’s written authorization;

d.

Incidental uses or disclosures;

e.

For the system directory or other persons involved in the enrolled person 's care;

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f.

To National security or intelligence;

g.

To correctional institutions or law enforcement as provided in 164.512 (k) (5); or

h.
Disclosures occurring prior to compliance date of April 14, 2003
ADHS/DBHS may temporarily suspend the right of the enrolled person to receive an accounting of disclosures as permitted under the HIPAA rule. For more detail about temporary suspension please see
Section 010 Accounting of Disclosures of Protected Health Information.
The ADHS/DBHS HIPAA Analyst is designated as the person/position title responsible for receiving requests for an accounting of disclosures made of enrolled persons’ Protected Health Information.

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SECTION 005:

Provision of Privacy Notice

A. PURPOSE:
To issue instructions to all ADHS/DBHS workforce members regarding the provision of a notice of privacy practices to enrolled persons.
B. PRIVACY NOTICE REQUIREMENTS:
Generally: Pursuant to 45 CFR 164.520, an enrolled person has a right to adequate notice of the uses and disclosures of his/her Protected Health Information that may be made by or on behalf of ADHS/DBHS, and of the enrolled person 's rights and ADHS/DBHS’ legal duties with respect to his/her Protected Health
Information.
Revisions to the Notice: ADHS/DBHS will promptly revise and distribute the HIPAA privacy notice whenever there is a material change to the uses or disclosures, the enrolled person 's rights, the Covered Entity 's legal duties, or other privacy practices described in the notice.
Provision of Notice: The ADHS/DBHS HIPAA Privacy Notice is posted on the ADHS/DBHS web site and is available electronically from the web site at http://www.hs.state.az.us/bhs/index.htm .
Documentation Requirements: ADHS/DBHS retains copies of Privacy Notices issued for a period of at least six years.
Please see Appendix C: ADHS/DBHS Notice of Privacy Practices for a copy of the notice.

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SECTION 006:

Complaint/Grievance Process for Alleged Violations of
Rights Relating to Protected Health Information

A. PURPOSE:
To issue instructions to all ADHS/DBHS workforce members regarding requirements for acceptance of, response to, and documentation of enrolled persons’ complaints/grievances about alleged violations of enrolled members’ privacy rights relating to Protected Health Information and eminating only from
ADHS/DBHS or its workforce.
Complaints/grievances involving Tribal or Regional Behavioral Health Authority privacy violations are not covered by this process and are handled by the Tribal or Regional Behavioral Health Authorities according to their policies and procedures.
B. COMPLAINT/GRIEVANCE REQUIREMENTS:
HIPAA grants enrolled persons specific rights relating to their health information, many of which overlap with patient/client rights mandated by state law. Specifically, in addition to privacy rights related to their Protected
Health Information, enrolled persons are granted the right to:
a.

access Protected Health Information in the designated record set,

b.

request restrictions on uses or disclosures of their Protected Health Information,

c.

request that communications related to Protected Health Information be confidential,

d.

request amendment of Protected Health Information in the designated record set, and

e.

receive an accounting of disclosures of their Protected Health Information.

HIPAA also mandates that a process be in place for enrolled persons to complain about ADHS/DBHS ' privacy related requirements or ADHS/DBHS ' compliance with those requirements.
The ADHS/DBHS Manager of Grievance and Appeals is designated as the person/position title responsible for receiving complaints/grievances relating to enrolled persons ' privacy rights and rights to access their designated record set. Please see Appendix H: Complaint Regarding Violation of Privacy of Protected
Health Information form.
When a HIPAA related complaint/grievance is communicated to any ADHS/DBHS workforce member, that workforce member shall immediately notify the ADHS/DBHS Manager of Grievance and Appeals and shall inform the grievant of the name and contact information for the ADHS/DBHS Manager of Grievance and
Appeals.
If the ADHS/DBHS Manager of Grievance and Appeals is a subject of the complaint/grievance, the grievant shall be referred directly to the ADHS Agency Privacy Officer, who will act as the complaint resolution agent for purposes of that complaint/grievance.
The ADHS/DBHS Manager of Grievance and Appeals shall also give the grievant information about his/her right to file a complaint with the U.S. Secretary of Health and Human Services.
The ADHS/DBHS Manager of Grievance and Appeals shall investigate the circumstances of the alleged
HIPAA privacy rights violation in accordance with the grievance procedures set forth in this manual and if appropriate, shall take all reasonable steps to mitigate the effects of any violation. In investigating and acting on the complaint/grievance, the ADHS/DBHS Manager of Grievance and Appeals may consult with the
ADHS Agency Privacy Officer.
The enrolled person (grievant) may file a privacy complaint up to 365 days from the date the grievant knew that the act or omission complained of occurred. Within 5 working days, ADHS/DBHS will inform the grievant in writing of the receipt of their complaint and the action to be taken (summary disposition,
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An extension of the timeline is permissible upon a showing of necessity. The request for extension must be in writing, copied to all parties, explain the reason(s) why an extension is necessary, and be submitted prior to the expiration of the original time period.
The ADHS/DBHS Manager of Grievance and Appeals shall communicate the results of the investigation and resolution of the complaint/grievance to the grievant and to the ADHS Agency Privacy Officer. If the grievant is dissatisfied with the result, he/she shall be informed of the right to file the complaint/grievance with the
U.S. Secretary of Health and Human Services.
If the results of the investigation indicate that an ADHS/DBHS workforce member made an unauthorized use or disclosure of Protected Health Information, or otherwise violated the HIPAA Privacy Rule and
Regulations, the ADHS/DBHS Manager of Grievance and Appeals shall report such finding to the ADHS
Agency Privacy Officer, who must also report such finding to the workforce member 's supervisor. In accordance with ADHS Level One policy and procedure OHR009 Discipline, effective 04/02/02, and its amendments, ADHS/DBHS will apply disciplinary actions, as appropriate, to members of its workforce who fail to comply with the ADHS/DBHS HIPAA Privacy Manual requirements or who fail to comply with the
HIPAA Privacy Rule.
ADHS/DBHS transmits HIPAA privacy complaint/grievance information to the ADHS Agency Privacy Officer regarding any HIPAA Privacy Violation and maintains HIPAA complaint/grievance documentation in accordance with ADHS and ADHS/DBHS policy and procedure. The documentation must be maintained for a minimum period of six (6) years from the date of final resolution.
There shall be no retaliation against any enrolled person, ADHS workforce member, the ADHS/DBHS
Manager of Grievance and Appeals, or the ADHS Agency Privacy Officer for having filed or assisted in the filing of a complaint/grievance, or for investigating or acting on a complaint/grievance. Any workforce member who becomes aware of any such retaliatory action shall immediately notify the ADHS Agency
Privacy Officer.

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SECTION 007:

Uses or Disclosure of Protected Health Information
Permitted Without Authorization

A. PURPOSE:
To issue instructions to all ADHS/DBHS workforce members regarding the use and disclosure of Protected
Health Information permitted without an authorization.
B. REQUIREMENTS:
1. Treatment, Payment or Health Care Operations
With the exception of protected health information related to HIV or other Confidential Communicable
Disease, ADHS/DBHS may use or disclose Protected Health Information for its payment or healthcare operations and for treatment activities delivered by its contracted health plans/health care providers and their subcontracted health care providers, provided that such use or disclosure is consistent with state and federal laws.
With the exception of protected health information related to HIV or other Confidential Communicable
Disease, ADHS/DBHS may disclose Protected Health Information to another covered entity, to a covered component/function of the State of Arizona Hybrid Covered Entity, agencies or organizations or vendors with which there is a current agreement for the enrolled person 's care or services, business associates of the
ADHS/DBHS, a health care provider for the payment activities of the entity that received the information, or other health care providers including mental health providers and social service and welfare agencies.
Payment:
Payment activities undertaken by ADHS/DBHS include those to obtain premiums, or to determine or fulfill
ADHS/DBHS’ responsibility for coverage, and provision of behavioral health care benefits, and to obtain or provide reimbursement for the provision of behavioral health care, including but not limited to:
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.

k.

determinations of eligibility (Non Title XIX) or coverage (including coordination of benefits or the determination of cost sharing amounts) adjudication or subrogation of claims risk adjusting amounts due based on enrolled person’s health status and demographic characteristics billing claims management collection activities obtaining payment under a contract for reinsurance including stop-loss insurance and excess of loss insurance related health care data processing review of health care services with respect to medical necessity, coverage under a plan, appropriateness of care or justification of charges utilization review activities
a. precertification of services
b. preauthorization of services
c. concurrent review of services
d. retrospective review of services disclosure to consumer reporting agencies of any of the following Protected Health Information relating to collection of premiums or reimbursement:
a. name and address
b. date of birth
c. social security number
d. payment history
e. account number
f. name and address of the health care provider and/or health plan

Health Care Operations:
With the exception of protected health information related to HIV or other Confidential Communicable
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Disease, ADHS//DBHS may use or disclose Protected Health Information to another covered entity, a covered component/function of the State of Arizona Hybrid Covered Entity, agencies, or organizations or vendors with which there is a current agreement for the enrolled person 's care or services, business associates of the ADHS/DBHS, other health care providers including mental health providers and social service and welfare agencies, or a health care provider for health care operations activities of the entity that receives the information, if each entity either has or had a relationship with the ADHS/DBHS enrolled person who is the subject of the Protected Health Information being requested, the Protected Health Information pertains to such relationship and the disclosure is for the purpose of:
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.
o.
p.
q.
r.
s.
t.
u.
v.

w.
x.
y.

health care fraud or abuse detection or compliance quality assessment and improvement activities outcomes evaluation development of clinical guidelines population based activities relating to improving health or reducing health care costs protocol development case management care coordination contacting health care providers and enrolled persons with information about treatment alternatives related functions that do not include treatment reviewing the competency or qualifications of health care professionals evaluating practitioner and provider performance evaluating health plan performance conducting training programs in which students, trainees or practitioners in areas of health care learn under supervision to practice or improve their skills as health care providers training non-health care professionals, accreditation activities certification activities licensing activities credentialing activities underwriting, premium rating and other activities related to the creation, renewal or replacement of a contract of health insurance or health benefits ceding, securing or placing a contract for reinsurance of risk relating to claims for health care including stop-loss insurance and excess of loss insurance conducting or arranging for
a. medical review
b. legal services
c. auditing functions including fraud or abuse detection or compliance programs business planning and development conducting cost-management and planning-related analysis related to managing and operating
ADHS/DBHS including formulary development and administration, development or improvement of methods of payment or coverage policies business management and general administrative duties of ADHS/DBHS including but not limited to:
a. management activities relating to implementation of and compliance with HIPAA
b. customer service including provision of data analysis for policy holders, plan sponsors, or other customers provided that Protected Health Information is not disclosed to such policy holder, plan sponsor or customer
c. resolution of internal grievances
d. the sale, transfer, merger or consolidation of all or part of ADHS/DBHS with another covered entity or an entity that following such activity will become a covered entity and due diligence related to such activity
e. creating of de-identified health information or a limited data set, and
f. fundraising for the benefit of the covered entity.

2. Family members actively participating in the enrolled person’s care, treatment or supervision
Limited Protected Health Information may be disclosed to family members actively participating in the enrolled person’s care, treatment or supervision, e.g., diagnosis, prognosis, need for hospitalization,
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anticipated length of stay, discharge plan, medication, medication side effects and short-term and long-term treatment goals

Under A.R.S. 36-509 (B), an agency or nonagency treating professional shall release the limited Protected
Health Information only after the treating professional or that person’s designee interviews the enrolled person undergoing treatment or evaluation to determine whether or not release is in that person’s best interests. A decision to release or withhold information is subject to review pursuant to section A.R.S. 36517.01. The treating agency shall record the name of any person to whom information is given.
If the enrolled person is present when protected health information is requested by a family member or other individual directly involved in the enrolled person’s care, the enrolled person must be given the opportunity to object to the disclosure of the protected health information. If the enrolled person agrees to the disclosure or does not express an objection to the disclosure, only the protected health information directly relevant to the person’s involvement with the enrolled person’s care or payment may be disclosed.
If the enrolled person is not present or the opportunity to agree or object to the use or disclosure cannot practicably be provided because of the enrolled person’s incapacity or an emergency circumstance,
ADHS/DBHS may, in the exercise of professional judgment, determine whether the disclosure is in the best interests of the enrolled person and, if so, disclose only the protected health information that is directly relevant to the requester’s involvement in the enrolled person’s health care. Please see Section 008 B.2.A.
Use or Disclosure of Protected Health Information Where Authorization, Agreement or Opportunity to Object is Required for more detail on this issue.
4. Public Responsibility Uses and Disclosures of Protected Health Information
State and federal law permits or requires certain uses or disclosures of Protected Health Information for various purposes related to public responsibility. Such uses and disclosures may be made without the agreement or authorization of the enrolled person. The following uses and disclosures fall within this category: A. Health Oversight Activities:
ADHS/DBHS may use or disclose Protected Health Information to a health oversight agency for health oversight activities authorized by law including:
a.
audits,
b.
civil, administrative or criminal investigations,
c.
inspections,
d.
licensing agencies,
e.
board of medical examiners,
f.
licensure or disciplinary actions,
g.
civil, administrative or criminal proceedings or actions, or
h.
other activities necessary for the appropriate oversight of the
1. health care system,
2. government benefit programs for which health information is relevant to beneficiary eligibility,
3. entities subject to government regulatory programs for which health information is necessary for determining compliance with program standards, or
4. entities subject to civil rights laws for which health information is necessary for determining compliance.
Specifically excluded from this category are investigations of an enrolled person that are not related to receipt of health care, a claim for public benefits related to health, or the qualification for, or receipt of, public benefits or services when an enrolled person’s health is integral to the claim for public benefits or services.
B. Public Health Activities:
1. Control disease or injury:
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Protected health information may be disclosed to a health oversight agency or public health authority authorized by law to collect or receive information for the purpose of preventing or controlling disease, injury, or disability, including but not limited to:

a.
b.
c.
d.

the reporting of disease or injury, reporting vital events such as birth and death, conducting public health surveillance, investigations or interventions, or by direction of a public health authority to an official of a foreign government agency that is acting in collaboration with a public health authority.

Please see Appendix L: Arizona Behavioral Health Preemption Guide for further detail on this issue.
2. Reporting Abuse or Neglect:
ADHS/DBHS may disclose Protected Health Information to a public authority or other appropriate government authority authorized by law to receive reports of incapacitated or vulnerable adult abuse, neglect, or exploitation, if the enrolled person agrees to the disclosure or the extent the disclosure complies with or is expressly authorized in A.R.S. 46-454. ADHS/DBHS may disclose the minimum necessary
Protected Health Information to a peace officer or Adult Protective Services worker when investigating the enrolled person’s alleged abuse, neglect or exploitation. ADHS/DBHS must then promptly inform the enrolled person that such a report has been made except if ADHS/DBHS believes, in the exercise of professional judgement, that informing the enrolled person would place the enrolled person at risk of serious harm or ADHS/DBHS would be informing a personal representative and ADHS believes the personal representative is responsible for the abuse, neglect or other injury and that informing the personal representative would not be in the best interests of the enrolled person.
ADHS/DBHS may disclose Protected Health Information to a public health authority or other appropriate government authority authorized by law to receive reports of child abuse or neglect. ADHS/DBHS may disclose the minimum necessary Protected Health Information to a peace officer or Child Protective Services worker when investigating the enrolled person’s alleged abuse, neglect or exploitation.
ADHS/DBHS may disclose Protected Health Information to the appropriate government authority to receive reports of an enrolled person’s abuse secondary to domestic violence. Upon written request, ADHS/DBHS may disclose the minimum necessary Protected Health Information to an authorized government authority when investigating the enrolled person’s alleged abuse. ADHS/DBHS must then promptly inform the enrolled person that such a report has been made except if ADHS/DBHS believes, in the exercise of professional judgement, that informing the enrolled person would place the enrolled person at risk of serious harm or ADHS/DBHS would be informing a personal representative and ADHS believes the personal representative is responsible for the abuse, neglect or other injury and that informing the personal representative would not be in the best interests of the enrolled person.
C. Food and Drug Administration:
ADHS/DBHS may disclose Protected Health Information to a person subject to the jurisdiction of the Food and Drug Administration (FDA) regarding his/her responsibility for quality, safety or effectiveness of an FDA regulated product or activity, to collect or report adverse events, product defects or problems, track FDAregulated products, enable product recalls, repairs or replacements, or lookbacks, or conduct post-marketing surveillance; D. Coroners or medical examiners:
ADHS/DBHS may disclose Protected Health Information to coroners or medical examiners to identify a deceased enrolled person or to determine cause of death.
E. Organ procurement:
ADHS/DBHS may disclose Protected Health Information to a designated organ procurement organization and tissue and eye banks.
F. Required by Law:

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ADHS/DBHS may use or disclose Protected Health Information to the extent such use or disclosure complies with and is limited to the requirements of law.
ADHS/DBHS may disclose Protected Health Information in the course of any judicial or administrative proceeding, in response to a court order, court ordered warrant issued by a judicial officer, a subpoena or grand jury subpoena, administrative request, civil or an authorized demand, similar process authorized by law, or administrative tribunal provided that ADHS/DBHS discloses only the Protected Health Information expressly authorized by the court order.
ADHS/DBHS may use or disclose Protected Health Information related to implementation of the Jason K
Settlement Agreement, including disclosing said information to other state agency workforce members involved in the care and treatment or payment for children and families receiving services through the
Arizona publicly funded behavioral health system. As of April 14, 2003, state agencies having declared themselves as covered components of the Arizona State Hybrid Covered Entity include:
Department of Economic Security/Division of Developmental Disabilities;
Department of Economic Security/Division for Children Youth and Families;
Department of Economic Security/Comprehensive Medical and Dental Plan;
Department of Economic Security/Refugee Resettlement;
Department of Economic Security/Arizona Families First Program and Subcontractors; and other state agencies as they are determined.
ADHS/DBHS may use or disclose protected health information related to the Arnold v Sarn judgement and its subsequent court orders including disclosing said information to the Office of the Court Monitor.
ADHS/DBHS may use or disclose Protected Health Information from or to the Arizona Center for Disability
Law, in its capacity as the federally mandated protection and advocacy agency for the state of Arizona.
Protected Health Information may be disclosed in response to a subpoena, discovery request, or other lawful process that is not accompanied by an order of a court or administrative tribunal if ADHS/DBHS received satisfactory assurance from the party seeking the information that reasonable efforts have been made by such party to ensure that the enrolled person who is the subject of the Protected Health Information has been given notice of the request or the party seeking the information has made reasonable efforts to secure a qualified protective order.
G. Law Enforcement:
Protected Health Information may be disclosed for the following law enforcement purposes and under the specified conditions:
1. Certain Injuries or Wounds:
ADHS/DBHS may disclose Protected Health Information as required by law, including laws that require reporting of certain types of wounds or other physical injuries.
2. Court Order, Court Ordered Warrant, Summons, Subpoena, Grand Jury Subpoena,
Administrative Request:
ADHS/DBHS may disclose Protected Health Information in compliance with and as limited by the relevant requirements of a court order or court-ordered warrant, subpoena or summons issued by a judicial officer; a grand jury subpoena, or an administrative request or a civil or an authorized investigative demand, or other similar process authorized under law. These disclosures may be made provided that:
a.

The information sought is relevant and material to a legitimate law enforcement inquiry;

b.

The request is specific and limited in scope to the extent reasonably practicable in light of the purpose for which the information is sought; and

c.

de-identified information could not reasonably be used.

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3. Suspect, Fugitive, Material Witness, or Missing Person:
ADHS/DBHS may disclose Protected Health Information to secure the return of a patient of the Arizona
State Hospital or in response to a law enforcement official’s request for information for the purpose of identifying or locating a suspect, fugitive, material witness, or missing person provided that only the following information, if known to ADHS/DBHS, is disclosed:
a.
b.
c.
d.
e.
f.
g.
h.

name and address date and place of birth social security number
ABO blood type and rh factor
Type of injury
Date and time of treatment
Date and time of death, if applicable, and
A description of distinguishing characteristics including height, weight, gender, race, hair and eye color, presence or absence of facial hair (beard of moustache) scars and tattoos.

4. Death of an enrolled person suspected as result of criminal conduct:
ADHS/DBHS may disclose a decedent’s Protected Health Information to alert law enforcement to an enrolled person’s death if ADHS/DBHS suspects that the death resulted from criminal conduct.
5. Enrolled Person is Victim of a Crime:
.
ADHS/DBHS may disclose Protected Health Information in response to a law enforcement official’s request for such information about an enrolled person who is or is suspected to be a victim of a crime if the enrolled person agrees to the disclosure, or ADHS/DBHS is unable to obtain the enrolled person’s agreement because of incapacity or other emergency circumstance provided that:
a.

The law enforcement official represents that such information is needed to determine whether a violation of law by a person other than the victim has occurred, and Such information is not intended to used against the victim;

b.

The law enforcement official represents that immediate law enforcement activity that depends on the disclosure would be materially and adversely affected by waiting until the enrolled person is able to agree to the disclosure; and

c.

The disclosure is in the best interests of the enrolled person as determined by ADHS/DBHS in the exercise of professional judgment.

6. Good Faith Belief of Criminal Conduct on ADHS/DBHS Premises:
ADHS/DBHS may disclose Protected Health Information to a law enforcement official that ADHS/DBHS believes in good faith constitutes evidence of criminal conduct that occurred on the premises of
ADHS/DBHS.
7. Reporting a Crime in Emergency Situations:
ADHS/DBHS may disclose Protected Health Information to a law enforcement official in order to report a crime in emergency situations.
ADHS/DBHS may disclose Protected Health Information to ambulance attendants in accordance with A.R.S.
12-2294.
H. Decedents:
Protected Health Information may be disclosed to coroners, medical examiners or funeral directors, as necessary for carrying out their duties, and to designated cadaver organ, eye or tissue donation procurement organizations, and tissue and eye banks.

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I. Specialized Government Functions:
1. Military and veteran activities:
ADHS/DBHS may use and disclose Protected Health Information for enrolled persons who are Armed
Forces and foreign military personnel for activities deemed necessary by appropriate military command authorities to assure the proper execution of the military mission, if the appropriate military authority has published by notice in the Federal Register the following information:
a.

appropriate military command authorities, and

b.

the purposes for which the Protected Health Information may be used or disclosed.

2. Intelligence and National Security:
ADHS may disclose Protected Health Information to authorized federal officials for the conduct of lawful intelligence, counter intelligence, and other activities authorized by the National Security Act.
3. Protective Services for the President and Others:
ADHS/DBHS may disclose Protected Health Information to authorized federal officials for the provision of protective services to the President, foreign heads of state, others designated by law, and for the conduct of criminal investigations of threats against such persons.
4. Correctional and law enforcement official:
ADHS/DBHS may disclose Protected Health Information to a correctional institution or a law enforcement official having lawful custody of an enrolled person if the correctional institution or law enforcement official represents that such Protected Health Information is necessary for:
a.

the provision of health care to the enrolled person;

b.

the health and safety of the enrolled person or other inmates;

c.

the health and safety of the officers or employees or others at the correctional institution;

d.

the health and safety of such individuals, officers, or other persons responsible for the transporting of inmates or their transfer from one institution, facility, or setting to another;

e.

law enforcement on the premises of the correctional institution;

f.

securing the return of a patient of the Arizona State Hospital; and

g.

the administration and maintenance of the safety, security and good order of the correctional institution. 5. Public Benefits:
Protected Health Information relevant to administration of a government program providing public benefits may be disclosed to another governmental program providing public benefits serving the same or similar populations as necessary to coordinate program functions or improve administration and management of program functions.
J. Avert Serious Threat to Health or Safety
ADHS/DBHS may disclose Protected Health Information if, in good faith, ADHS/DBHS believes the disclosure is necessary to prevent harm, or prevent or lessen a serious and imminent threat to the health and safety of a person or the public, including the target of the threat. Disclosures may be made to a person or persons reasonably able to prevent or lessen the threat, including the target of the threat.
Disclosures may be made if it is necessary for law enforcement authorities to identify or apprehend an enrolled person because of a statement by the enrolled person admitting participation in a violent crime that
ADHS/DBHS reasonable believes may have caused serious physicial harm to the victim, or where it
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K. Workers ' Compensation:
Protected Health Information may be disclosed as authorized and to the extent necessary to comply with laws relating to workers ' compensation and other similar programs.
L. Reporting ADHS/DBHS Conduct By a Workforce Member
An ADHS/DBHS workforce members may report Protected Health Information to his/her attorney or a health oversight agency, public health authority or health care accreditation organizaion related to a good faith belief that ADHS/DBHS has engaged in conduct that is unlawful or violates professional or clinical standards, or that care, services, or conditions provided by ADHS/DBHS potentially endangers one or more enrolled persons, workers or the public.
M. Personal Representatives
ADHS/DBHS may disclose Protected Health Information to persons acting as a personal representative for the enrolled person including:
a.
b.
c.
d.
e.
f.
g.
h.
i.
j.

a personal representative of an unemancipated minor, the guardian of a minor or permanent guardian of a minor who is a dependent child, a person delegated powers by a parent or guardian, a guardian of an incapacitated person, a surrogate health care decision maker, health care decision makers, married or homeless minors, an agent appointed under a health care directive, a person with legal authority to act on behalf of a deceased individual or the estate, or an agent under mental health care power of attorney;

Please see Appendix L: Arizona Behavioral Health Preemption Guide for further detail on this issue.
N. Research
Persons doing research if the information is de-identified as prescribed in HIPAA. Identifying information requires the enrolled person’s authorization or a waiver of authorization as prescribed in HIPAA. Please see
Appendix L: Arizona Behavioral Health Preemption Guide for further detail on this issue;
O. Sexually Violent Persons Program
The Sexually Violent Persons Program provided that the disclosure is limited to the purposes of the SVP Act or if ordered by the court or if the covered entity discloses for purposes of treatment, payment or health care operations - please see Appendix L: Arizona Behavioral Health Preemption Guide for further detail on this issue; P. Human Rights Committees
Human Rights Committees if the redacted information complies with HIPAA de-identification requirements and if identifying protected health information is requested by the Human Rights Committees for official purposes the disclosure is permitted without enrolled person authorization to the Committee in its capacity as a health oversight agency - please see Appendix L: Arizona Behavioral Health Preemption Guide for further detail on this issue..

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SECTION 008:

Use or Disclosure of Protected Health Information
Where Authorization, Agreement or Opportunity To
Object Is Required

A. PURPOSE:
To issue instructions to all ADHS/DBHS workforce members regarding the use and disclosure of Protected
Health Information when use or disclosure is for purposes outside of those permitted by law.
B. REQUIREMENTS:
Except as otherwise permitted or required by HIPAA rules or Arizona Law, ADHS/DBHS may only use or disclose Protected Health Information so long as the consent obtained under the state statute A.R.S. 36509(a)(2) meets the authorization requirements in HIPAA 164.508 for disclosures that require a valid authorization. Under HIPAA, consent differs from authorization and is permissive, but not mandatory, for the disclosure of
Protected Health Information for treatment, payment or health care operations as required or permitted under HIPAA.
The enrolled person may give consent to use or disclose protected health information for purposes of treatment, payment or health care operations; however such consent is not required under HIPAA. For more detail regarding this issue, please refer to Appendix L: Arizona Behavioral Health Preemption Guide.
1. When Authorization is Required:
A. Psychotherapy Notes:
ADHS/DBHS must obtain an authorization for any use or disclosure:

a. of psychotherapy notes, except to carry out the following treatment, payment or health care operations:
a. use by the originator of the psychotherapy notes for treatment;
b. use or disclosure by ADHS/DBHS for its own training programs in which students, trainees, or practitioners in mental health learn under supervision to practice or improve their skills in group, joint, family or individual counseling;
c. use or disclosure by ADHS/DBHS to defend itself in a legal action or other proceeding brought by the enrolled person;
b. as required to the enrolled person
c. as required to the Secretary of the U.S. Department of Health and Human Services; or
d.

use or disclosure as permitted: i.e.,
a. to the enrolled person,
b. for treatment, payment or health care operations,
c. pursuant to and compliant with a valid authorization,
d. pursuant to an agreement made with the enrolled person, or
e. in compliance with requirements for de-identification, limited data sets and for underwriting and related purposes.

B. Marketing:

ADHS/DBHS must obtain a valid authorization for any use or disclosure of Protected Health
Information for marketing except if the communication is in the form of a face-to-face communication made by ADHS/DBHS to an enrolled person or a promotional gift of nominal value provide by ADHS/DBHS. If the marketing involves direct or indirect remuneration to
ADHS/DBHS from a third party, the authorization must state that such remuneration is involved.
C. Department of Education or School Districts:
ADHS/DBHS must obtain a valid authorization from the enrolled person, or their parents, or legal guardian for any use or disclosure to the Department of Education or school districts of Protected Health Information
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D. Alcohol and Substance Abuse Authorizations and Requirements :
Protected Health Information obtained by a federally assisted program that provides substance abuse diagnosis, treatment, or referral for treatment related to substance abuse is kept strictly confidential and is used or disclosed only in accordance with the requirements of federal law (42 U.S.C. 290dd-3, 42 U.S.C.
290ee-3, and 42 C.F.R., Part 2).
Please see Appendix I: Authorization for Disclosure of Substance Abuse or Confidential Communicable
Disease/HIV Information. See Appendix L: Arizona Behavioral Health Preemption Guide for further details regarding this issue.
E. HIV and Confidential Communicable Disease Requirements:
All Protected Health Information related to HIV is kept strictly confidential even if it is being used or disclosed for purposes of treatment, payment or health care operations and is used or disclosed only in accordance with the requirements of state law (A.R.S. § 36-664).
If a disclosure of confidential communicable disease related information is made pursuant to an authorization, the disclosure must be accompanied by a statement in writing which warns that the information is from confidential records which are protected by state law and that prohibits further disclosure of the information without specific written consent of the enrolled person to whom it pertains or as otherwise permitted by law.
An enrolled person may revoke an authorization at any time, provided that the revocation is in writing except to the extent that ADHS/DBHS has taken action in reliance on the authorization.
Please see Appendix I: Authorization for Disclosure of Substance Abuse or Confidential Communicable
Disease/HIV Information
F. Legal Representatives of the Enrolled Person:
ADHS/DBHS must obtain a valid authorization for disclosure to persons legally representing the enrolled person, e.g. an attorney or advocate, unless the legal representative qualifies as a personal representative.
G. All Other Parties/Requesters Not Permitted Use or Disclosure as Specified in the HIPAA Rule or state law: ADHS/DBHS must obtain a valid authorization for any other use or disclosure of Protected Health
Information. These circumstances include, but are not limited to:
•
•
•
•
•

Legislators,
Governor’s Office,
Non-Custodial Parent in instances where a court order specifically limits access to heath information – needs to be reviewed on a case by case basis with HIPAA Analyst and Attorney
General,
State or Federal Agencies or health care providers that are not covered entities or are not permitted disclosure under the HIPAA Rule or by federal or state law, and
Persons in Child and Family Teams not associated with a state agency or health care provider.

H. Valid Authorizations:
Valid authorizations are written in language that is understandable and contain the following required elements: a.

a description of the information to be used or disclosed that identifies the information in a specific and meaningful fashion;

b.

the name or other specific identification of the person(s) or class of persons authorized to

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c.

the name or other specific identification or the person(s) or class of persons to whom the covered entity may make the requested use or disclosure;

d.

a description of each purpose of the requested use or disclosure; the statement “at the request of the enrolled person” is a sufficient description of the purpose when an enrolled person initiates the authorization and does not, or elects not to, provide a statement of purpose;

e.

an expiration date or an expiration event that relates to the enrolled person or the purpose of the use of disclosure; the statement “end of the research study,” “none,” or similar language is sufficient if the authorization is for a use or disclosure of Protected Health Information for research, including the creation and maintenance of a research database or research repository; f.

the signature of the enrolled person and date; and

g.

if the authorization is signed by a personal representative of the enrolled person, a description of such representative’s authority to act for the enrolled person must also be provided.

The following statements are required for inclusion in the authorization:
a.

the enrolled person has the right to revoke the authorization in writing;

b.

there are not conditions for treatment, payment, enrollment or eligibility for benefits on whether the enrolled person signs the authorization; and

c.

there is potential for the Protected Health Information disclosed to be subject to redisclosure by the recipient and it may no longer be protected with the exception of HIV or other confidential communicable disease information which is prohibited from redisclosure.

An authorization is not valid if any of the following defects exist:
a.

the expiration date has passed;

b.

the expiration event is known by ADHS/DBHS to have occurred,

c.

the authorization has not been filled out completely;

d.

the authorization has been known by ADHS/DBHS to have been revoked;

e.

any material information in the authorization is known by ADHS/DBHS to be false;

f.

the authorization does not meet requirements for a compound authorization;

g.

ADHS/DBHS has conditioned the provision of treatment, payment, enrollment in the publicly funded behavioral health system, or eligibility for Non-Title XIX benefits on the provision of an authorization except as:
a.

relating to the provision of research related treatment; or

b.

relating to enrollment in the publicly funded behavioral health system if the authorization is sought for ADHS/DBHS’ eligibility or enrollment determinations relating to the individual or
ADHS/DBHS’ underwriting or risk rating determinations and the authorization is not for use or disclosure of psychotherapy notes.

Please see Appendix I: Authorization for Use or Disclosure of Protected Health Information
I. Revocation of a Valid Authorization:
An enrolled person may revoke an authorization at any time provided that the revocation is in writing, except to the extent that:
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a.

there has been action taken in reliance on the authorization; or

b.

if the authorization was obtained as a condition of obtaining insurance coverage, other law provides the insurer with the right to contest a claim under the policy or the policy itself.

J. Documentation of the Authorization:
ADHS/DBHS will keep documentation of any signed authorization for six (6) years from the date of creation or the date when it was last in effect, whichever is later.
2. When an Agreement or an Opportunity to Object is Required:
In the following circumstances, ADHS/DBHS may disclose Protected Health Information as outlined in
HIPAA provided the enrolled person is informed in advance of the use or disclosure and the enrolled person has the opportunity to agree to, object to, and limit or restrict the use or disclosure.
A. Involvement in Enrolled Person’s Care:
ADHS/DBHS may disclose to a family member, other relative, a close personal friend of the enrolled person, or any other person identified by the enrolled person, the Protected Health Information directly relevant to such person’s involvement with the enrolled person’s care or payment, if the enrolled person is given an opportunity to verbally agree or object to the disclosure.
ADHS is required to either:
a.

obtain the enrolled person’s verbal agreement;

b.

provide the enrolled person with the opportunity to verbally object to the disclosure and the enrolled person does not object;

c.

if the enrolled person is not present, or cannot be provided the opportunity to agree or object because of the enrolled person’s incapacity, ADHS/DBHS may, in the exercise of professional judgment, determine whether the disclosure is in the best interests of the enrolled person and, if so, disclose only the Protected Health Information that is directly relevant to the person’s involvement with the enrolled person’s health care.

Please refer to Section 007 Use or Disclosure of Protected Health Information Permitted Without
Authorization, Part B.2. for further information regarding release of limited protected health information to family members actively involved in the enrolled person’s treatment.
B. Notification:
a.

ADHS/DBHS may use or disclose Protected Health Information to notify, or assist in the notification of (including identifying or locating), a family member, a personal representative of the enrolled person, or another person responsible for the care of the enrolled person of the following: a.
b.

The enrolled person’s general condition; or

c.
b.

The enrolled person’s location;

The enrolled person’s death.

If the enrolled person is present for, or otherwise available prior to, a use or disclosure to a family member, other relative, a close personal friend of the enrolled person, or any other person identified by the enrolled person, and the enrolled person is capable of making health care decisions, ADHS/DBHS must either:
a.

Obtain the enrolled person’s verbal agreement;

b.

Provide the enrolled person with the opportunity to object to the disclosure and the

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c.
c.

Reasonably infer from the circumstances, based on the exercise of professional judgment, that the enrolled person does not object to the disclosure.

If the enrolled person is not present, or cannot be provided the opportunity to agree or object because of the enrolled person’s incapacity, ADHS/DBHS may, in the exercise of professional judgment, determine whether the disclosure is in the best interests of the enrolled person and, if so, disclose only the Protected Health Information that is directly relevant to the person’s involvement with the enrolled person’s health care.

C. Disaster relief:
To the extent that ADHS/DBHS in the exercise of its professional judgment, determines that it will not interfere with the ability to respond to emergency circumstances, ADHS/DBHS may use or disclose
Protected Health Information from or to a public or private entity authorized by law or by its charter to assist in disaster relief efforts, for the purpose of coordinating with such entities the enrolled person’s location, general condition, or death.

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SECTION 009:

Disclosure of Protected Health Information for Research
Purposes

A. PURPOSE:
To provide the ADHS/DBHS workforce with instructions relating to the use or disclosure of Protected Health
Information for research purposes.
B. RESEARCH REQUIREMENTS:
ADHS/DBHS may conduct research if the enrolled person signs a valid authorization agreeing to participate in the research.
ADHS/DBHS is permitted to use or disclose Protected Health Information for research without authorization provided that:
a.

documentation is obtained that an alteration to or waiver, in whole or in part, of the required authorization for use or disclosure of Protected Health Information has been approved by either an Institutional Review Board or a privacy board that meets the requirements of the
HIPAA rule, and

b.

ADHS/DBHS obtains from the researcher representations that:
a.

Use or disclosure is sought solely to review Protected Health Information as necessary to prepare a research protocol or for similar purposes preparatory to research,

b.

No Protected Health Information is to be removed from ADHS/DBHS by the researcher in the course of the review, and

c.

The Protected Health Information for which use or access is sought is necessary for the research purposes.

If research involves decedents’ Protected Health Information, ADHS/DBHS obtains from the researcher:
a.

representation that the use or disclosure is sought solely for research on the Protected Health
Information of decedents,

b.

documentation of the death of such individuals, and

c.

representation that the Protected Health Information for which use or disclosure is sought is necessary for research purposes.

If a waiver is obtained from the Institutional Review Board or privacy board, the documentation of the waiver must include all of the following:
a.

a statement identifying the IRB or privacy board (including the ADHS Human Subjects
Committee and the Arizona State Hospital Research Committee) and the date on which the alteration or waiver of authorization was approved;

b.

a statement that the IRB or privacy board has determined that the alteration or waiver, in whole or in part, of authorization satisfies the following criteria:
a.

the use or disclosure of Protected Health Information involves no more than a minimal risk to the privacy of enrolled persons based on, at least, the presence of the following elements: i. an adequate plan to protect the identifiers from improper use and disclosure; ii. an adequate plan to destroy the identifiers at the earliest opportunity consistent with conduct of the research unless there is a health or research justification for retaining the identifiers or such retention is otherwise required by law; and

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b.

The research could not practicably be conducted without the waiver or alteration; and

c.

The research could not practicably be conducted without access to and use of the
Protected Health Information.

c.

A brief description of the Protected Health Information for which use or access has been determined to be necessary by the IRB or privacy board;

d.

A statement that the alteration or waiver of authorization has been reviewed and approved under either normal or expedited review procedures, as follows:
a.
b.

A privacy board must review the proposed research at convened meetings at which members of the privacy board are present as specified in the HIPAA rule;

c.

The alteration or waiver of authorization must be approved by the majority of the privacy board members present at the meeting unless the privacy board elects to use an expedited review procedure in accordance with the HIPAA rule;

d.

e.

An IRB must follow requirements of the Common Rule including the normal review procedures or the expedited review procedures as referenced in the HIPAA rule;

A privacy board may use an expedited review procedure if the research involves no more than minimal risk to the privacy of the enrolled persons who are the subject of the
Protected Health Information for which use or disclosure is being sought; and

The chair or other member, as designated by the chair, of the IRB or the privacy board, as applicable, must sign the documentation of the alteration or waiver of authorization.

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SECTION 010:

Accounting for Disclosures of Protected Health
Information

A. PURPOSE:
To issue instructions to all ADHS/DBHS workforce members regarding the provision of an accounting of disclosures of Protected Health Information.
B. REQUIREMENTS:
1. Right to Receive and Accounting:
In compliance with 45 CFR 164.528, an enrolled person has a right to receive an accounting of disclosures of Protected Health Information by ADHS/DBHS during a time period specified up to six (6) years prior to the date of the request for an accounting except for the following disclosures:
a.

To carry out treatment, payment and health care operations as permitted under law;

b.

To the enrolled person about his or her own information;

c.

For the system directory or to persons involved in the enrolled person 's care, or other notification purposes permitted under law;

d.

Pursuant to the enrolled person 's authorization;

e.

For national security or intelligence purposes;

f.

To correctional institutions or law enforcement officials as permitted under law

g.

As part of a limited data set; or

h.

That occurred prior to April 14, 2003.

To request an accounting of disclosures made by ADHS/DBHS, please use the form in Appendix J: Request for an Accounting of Disclosures.
2. Temporary Suspension of Right:
ADHS/DBHS will temporarily suspend an enrolled person’s right to receive an accounting of disclosures to a health oversight agency, public health authority or health care accreditation organizaion, or law enforcement official as provided in the HIPAA rule for the time specified by such agency or official, if the agency or official provides ADHS/DBHS a written statement asserting that the provision of an accounting would be reasonably likely to impede the activities of the agency or official and specifying a time period for the suspension.
If the agency or official statement is made orally, ADHS/DBHS must document the statement including the identity of the agency or official making the statement, temporarily suspend the enrolled person’s right to an accounting of disclosures subject to the statement, and limit the temporary suspension to no longer than 30 days from the date of the oral statement unless a written statement is submitted during that time.
3. Content of the Accounting:
The written Accounting must meet the following requirements:
Other than as excepted above, the Accounting must include disclosures of Protected Health Information that occurred during the six (6) years (or such shorter time period as is specified in the request) prior to the date of the request, including disclosures by or to business associates;
The accounting for each disclosure must include:
a.

Date of disclosure;

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b.

Name of entity or person who received the Protected Health Information, and, if known, the address of such entity or person;

c.

A brief description of the Protected Health Information disclosed;

d.

A brief statement of the purpose of the disclosure that reasonably informs the enrolled person of the basis for the disclosure, or in lieu thereof, a copy of the enrolled person 's authorization or the request for a disclosure;

e.

If, during the time period for the accounting, multiple disclosures have been made to the same entity or person for a single purpose, or pursuant to a single authorization, the accounting may provide the information as set forth above for the first disclosure, and then summarize the frequency, periodicity, or number of disclosures made during the accounting period and the date of the last such disclosure during the accounting period;

f.

If, during the period covered by the accounting, ADHS/DBHS has made disclosures of Protected
Health Information for a particular research purpose for 50 or more individuals, the accounting may provide: a.
b.

A description, in plain language, of the research protocol or other research activity including the purpose of research and the criteria for selecting particular records,

c.

A brief description of the type of Protected Health Information that was disclosed,

d.

The date or period of time during which such disclosures occurred, or may have occurred, including the date of the last such disclosure during the accounting period,

e.

The name, address, and telephone number of the entity that sponsored the research and of the researcher to whom the information was disclosed, and

f.
g.

The name of the protocol or other research activity,

A statement that the Protected Health Information of the enrolled person may or may not have been disclosed for a particular protocol or other research activity.

If, during the period covered by the accounting, ADHS/DBHS provides an accounting for research disclosures, and if it is reasonably likely that the Protected Health Information of the enrolled person was disclosed for such research protocol or activity, ADHS/DBHS shall, at the request of the enrolled person, assist in contacting the entity that sponsored the research and the researcher.

4. Provision of the Accounting:
The enrolled person 's request for an accounting must be acted upon no later than sixty (60) days after receipt, as follows:
a.

Provide the accounting as requested, or

b.

If unable to provide the accounting within sixty (60) days, the time for response may be extended by no more than thirty (30) additional days, provided that:
i. Within the first sixty (60) days, the enrolled person is given a written statement of the reasons for the delay and the date by which the accounting will be provided; and ii. There are no additional extensions of time for response.

c.

The first accounting in any twelve-month period must be provided to the enrolled person without charge. A reasonable, cost-based fee may be charged for additional accountings within the twelve month period, provided the enrolled person is informed in advance of the fee, and is permitted an opportunity to withdraw or amend the request.

ADHS/DHBS will provide a response to a request for an accounting by sending the requestor the Response
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5. Documentation Requirements: The entity must document and retain documentation, in written or electronic format, for a period of six years:
a.

All information required to be included in an accounting of disclosures of Protected Health
Information;

b.

All written accountings provided to enrolled persons, and;

c.

The titles of persons or offices responsible for receiving and processing requests for an accounting from enrolled persons.

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SECTION 011:

Definitions

Business Associate (BA) means a person or entity who, on behalf of the department, or an office, program or facility of the department, but not in the capacity of a workforce member, performs, or assists in the performance of, a function or activity involving the use or disclosure of Protected Health Information, or provides legal, actuarial, accounting, consulting, data aggregation, management, administrative, accreditation, or financial services involving disclosure of Protected Health Information.
Complaint means any concern communicated by a person questioning any act or failure to act relating to an enrolled person 's rights to access his/her Protected Health Information or other information in the designated record set to maintain the privacy of his/her health information, to request restrictions on uses or disclosures of his/her Protected Health Information or other information in the designated record set, to request confidential communications regarding his/her Protected Health Information or other information in the designated record set, to request amendment of his/her Protected Health Information or other information in the designated record set, or to receive an accounting of disclosures of his/her Protected
Health Information.
Covered Entity (CE) means a health plan, a health care clearinghouse, or a health care provider that transmits any health information in electronic form relating to any covered transaction. The State of Arizona is the Hybrid Covered Entity and ADHS/DBHS is a health plan under the HIPAA rule definition.
Designated Record Set means the enrollment, payment, claims adjudication, and case or medical management systems maintained by or for ADHS/DBHS as a health plan, or used, in whole or in part, by or for ADHS/DBHS to make decisions about enrolled persons. The ADHS/DBHS designated record set consists of all data fields and valid values contained in the Client Information System (CIS).
De-Identified Information means health information that does not identify an enrolled person and with respect to which there is no reasonable basis to believe that the information can be used to identify the enrolled person. Health information may be considered not to be individually identifiable in the following circumstances: 1.

A person with appropriate knowledge and experience with generally acceptable statistical and scientific principles and methods determines that the risk is very small that the information could be used, alone or with other reasonably available information, to identify the enrolled person who is the subject of the information;

or
2.

The following identifiers of the enrolled person (and relatives, employers or household members) have been removed:
a. names;
b. information relating to the enrolled person 's geographic subdivision;
c. age;
d. telephone numbers;
e. fax numbers;
f. email addresses;
g. social security numbers;
h. medical record numbers;
i. health plan beneficiary numbers;
j.
account numbers;
k. certificate or license numbers;
l. vehicle identifiers and serial numbers, including license plate numbers;
m. device identifiers and serial numbers;
n. Web Universal Resource Locators (URLs);
o. Internet Protocol (IP) address numbers;
p. biometric identifiers;
q. full face photographic images; and,
r. any other unique identifying number, characteristic or code.

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Disclosure means the release, transfer, provision of access to, or divulging in any other manner, of information outside the entity holding the information.
Family Member - Under A.R.S. 36-501 (14), “family member” means a spouse, parent, adult child, adult sibling or other blood relative of an enrolled person undergoing treatment or evaluation.
Grievance means a formal request for review of a HIPAA Privacy complaint or further review of any unresolved complaint related to an alleged HIPAA Privacy violation eminating from a member of the
ADHS/DBHS workforce that may be initiated orally or in writing.
Grievant means the enrolled person who initiates a complaint or grievance.
Health Care Operations includes functions such as quality assessment and improvement activities, reviewing competence or qualifications of health care professionals, conducting or arranging for medical review, legal services and auditing functions, business planning and development, and general business and administrative activities.
Health Oversight Agency means a governmental agency or authority, or a person or entity acting under a grant of authority from, or a contract with, such a public agency, including the employees or agents of the public agency, its contractors and those to whom it has granted authority, that is authorized by law to oversee the public or private health care system or government programs in which health information is necessary to determine eligibility or compliance.
Hybrid Entity means a single legal entity that is a Covered Entity whose covered functions are not its primary functions.
Individually Identifiable Information means a subset of health information (including demographic information collected from an enrolled person or information created or received by a health care provider, health plan, employer or health care clearinghouse) that:
-

identifies the individual or with respect to which there is a reasonable basis to believe the information can be used to identify the individual, and relates to the provision of health care to an individual, or the past, present, or future physical or mental health or condition of an individual, or the past, present, or future payment for the provision of health care to an enrolled person;

and includes the following data elements:
a.
b.

c.
d.
e.
f.
g.
h.
i.
j.
k.
l.
m.
n.

names; information relating to the enrolled person 's geographic subdivision;
a. zip code
b. census tract
c. street address
d. city
e. county
f. geographic service area age; telephone numbers; fax numbers; email addresses; social security numbers; medical record numbers; health plan beneficiary numbers;
a. AHCCCS ID
b. CIS ID account numbers;
a. Health Plan Name certificate or license numbers; vehicle identifiers and serial numbers, including license plate numbers; device identifiers and serial numbers;
Web Universal Resource Locators (URLs);

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o.
p.
q.
r.

Internet Protocol (IP) address numbers; biometric identifiers; full face photographic images; and, any other unique identifying number, characteristic or code.

Minimum Necessary requires ADHS/DBHS to take reasonable steps to limit the use of or disclosure to requests for Protected Health Information to the minimum necessary information to accomplish the intended purpose of the request.
Payment means activities undertaken to obtain or provide reimbursement for health care, including determinations of eligibility or coverage, billing, collections activities, medical necessity determinations and utilization review.
Personal Representative means a person who has authority under applicable law to make decisions related to health care on behalf of an adult or minor, or the parent, guardian, or other person acting in loco parentis who is authorized under law to make health care decisions on behalf of a minor, except where the minor is authorized by law to consent, on his/her own or via court approval, to a health care service.
Privacy Notice means the ADHS/DBHS Notice of Privacy Practices, relating to ADHS/DBHS’ use and disclosure of Protected Health Information, as required under HIPAA regulations for distribution to all enrolled persons whose information will be collected by or on behalf of ADHS/DBHS.
Protected Health Information means individually identifiable information relating to the past, present or future physical or mental health or condition of an enrolled person, the provision of health care to an enrolled person, or the past, present or future payment for health care provided to an enrolled person. It does not include individually identifiable information in education records covered by the Family Educational Right and Privacy Act, as amended, 20 U.S.C. 1232g and 1232g(a)(4)(B)(iv); education records, files, documents and other materials which contain information directly related to a student and which are maintained by an educational agency or institution or by a person acting for such agency or institution; and employment records held by a covered entity in its role as an employer.
Psychotherapy notes means notes recorded in any medium by a health care provider who is a mental health professional documenting or analyzing the contents of a conservation during a private counseling session and that are separate from the rest of the enrolled person 's medical record. Psychotherapy notes excludes medication prescription and monitoring, counseling sessions start and stop times, the modalities and frequencies of treatment furnished, results of clinical tests, and any summary of the following items: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date.
Public Health Authority means a governmental agency or authority, or a person or entity acting under a grant of authority from or a contract with such a public agency, including the employees or agents of the public agency, its Contractors and those to whom it has granted authority, that is responsible for public health matters as part of its official mandate.
Treatment means the provision, coordination, or management of health care and related services, consultation between providers relating to an enrolled person, or referral of an enrolled person to another provider for health care.
Use means, with respect to individually identifiable health information, the sharing, employment, application, utilization, examination, or analysis of such information within an entity that maintains such information.
Workforce Members means employees, volunteers, trainees and other persons whose conduct, in the performance of work for ADHS/DBHS, its offices, programs or facilities, is under the direct control of
ADHS/DBHS, regardless of whether they are paid by ADHS/DBHS.

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SECTION 012:

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Appendix A: ADHS/DBHS Workforce Training Materials
Level 2 HIPAA Training Slides

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EMPLOYEE CONFIDENTIALITY ACKNOWLEDGEMENT

I hereby acknowledge, by my signature below, that I understand that the Protected Health
Information (PHI), other confidential records, and data related to enrolled persons to which I have knowledge and access to in the course of my employment with Arizona Department of Health
Services, Division of Behavioral Health Services ADHS/DBHS is to be kept confidential and this confidentiality is a condition of my employment. This information shall not be disclosed to anyone under any circumstances, except to the extent necessary to fulfill my job requirements.
I am familiar with the HIPAA Privacy guidelines at ADHS/DBHS pertaining to the use and disclosure of PHI. Authorization should first be obtained before any disclosure of PHI as required in the HIPAA Privacy Manual.
I certify that I have received training in the HIPAA Privacy Rules

Signature:
Date:

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Appendix B: Minimum Necessary Criteria Checklist

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MINIMUM NECESSARY CRITERIA CHECKLIST

The Minimum Necessary standard for disclosure applies to: uses or disclosures requiring the enrolled person to have an opportunity to agree or object uses or disclosures by external business associates uses or disclosures that are permitted without authorization except for those required by law or for purposes of treatment, payment or health care operations or for public responsibility.
The Minimum Necessary Criteria Checklist is intended for use by the ADHS/DBHS Workforce to determine if disclosure to covered entities, business associates, by reason of law, or pursuant to and in compliance with a valid authorization is performed in compliance with the Minimum Necessary standard as required by HIPAA.
For non-routine disclosures of Protection Health Information, i.e., disclosures other than those permitted without authorization or pursuant to and in compliance with a valid authorization, the following criteria are applied. The
ADHS/DBHS workforce member must complete each section below as part of the Minimum Necessary determination:
1. Identification and authority of the requesting party has been verified* by means of:

2. What is the specific purpose of the request?:

3. What is the specific Protected Health Information being requested?:

4. Will a summary of the Protected Health Information requested achieve the intended purpose?:

6. Will de-identified or aggregate information achieve the intended purpose?:

Has the requesting party

attempted, or

obtained an authorization from the enrolled person?:

Verification:
ADHS/DBHS may rely on any of the following to verify the identity of a public official or person acting on the public official’s behalf:
•
•
•
•
•

if the request is made in person, an agency identification badge, other official credentials, or other proof of government status; if the request is made in writing, the request is on appropriate government letterhead; if the disclosure is to a person acting on behalf of the public health official, a written statement on appropriate government letterhead that the person is acting under the government’s authority or similar evidence that establishes the person’s identity; a written statement on appropriate government letterhead of the legal authority under which the information is requested, or if impracticable, an oral statement; or if the request is made pursuant to legal process, warrant, subpoena, order or other legal process, it is presumed to constitute legal authority.

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Appendix C: ADHS/DBHS Notice of Privacy Practices

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Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW
CAREFULLY.
Our Duty to Safeguard Your Protected Health Information
Individually identifiable information, maintained in the ADHS/DBHS designated record set, about your past, present, or future health or condition, the provision of behavioral health care to you, or payment for the behavioral health care is considered "Protected Health Information" (PHI).
The Arizona Department of Health Services/Division of Behavioral Health Services (ADHS/DBHS) may change our policies at any time. However, before we make a material revision to our policies, we will change our notice of information practices and deliver the revised notice as required by law. The revised notice will be effective for all Protected Health Information that we maintain at that time. Except when required by law, a material change to any term of the notice may not be implemented prior to the effective date of the notice in which such material change is reflected.
You can also request a copy of our notice at any time by accessing our website at http://www.hs.state.az.us/bhs/index.htm or by calling the office and requesting that a revised copy be sent to you in the mail. For more information about our privacy practices, please see the contact person listed on page 3.
How We May Use and Disclose Your Protected Health Information
The ADHS/DBHS uses or discloses PHI for a variety of reasons. We have a limited right to use or disclose your PHI for purposes of treatment, payment and behavioral health care operations. For uses or disclosures, we must have your written authorization unless the law permits or requires us to make the use or disclosure without your authorization. You also have the right to revoke your authorization. If we disclose your PHI to a business associate in order for that entity to perform a function on our behalf, we must have in place an agreement from the business associate that it will extend the same degree of privacy protection to your information that we must apply to your PHI. However, the law provides that we are permitted to make some uses or disclosures without your consent or authorization. The following offers more description and some examples of our potential uses or disclosures of your PHI.
Uses and Disclosures Relating to Treatment, Payment, or Behavioral Health Care Operations.
Generally, we may use or disclose your PHI as follows:
For treatment: We may use or disclose your PHI to provide, coordinate, or manage your healthcare and any related services. For example, your PHI will be shared among members of your treatment team, or with the ADHS/DBHS staff. Your PHI may also be shared with outside entities performing other services relating to your treatment. Some of these services include communicating with health professionals and state agency workforce members to plan your care and treatment or for consultation. Your information may also be shared for treatment and care with the Regional Behavioral Health Authorities, Tribal Regional Behavioral Health Authorities and their subcontracted providers.
For payment: We may use or disclose your PHI in order to bill and collect payment for your behavioral health care services. For example, we may contact your employer to verify employment status, and/or release portions of your PHI to the “Arizona Medicaid Agency” (Arizona Health Care
Cost Containment System [AHCCCS]) or the ADHS central office. We may also use or disclose your PHI to Regional Behavioral Health Authorities and Tribal Regional Behavioral Health
Authorities and their subcontracted providers or a private insurer to get paid for services that we delivered to you.
For behavioral health care operations: We may use or disclose your PHI for behavioral health care operations. For example, members of the team may share PHI to assess the care and outcomes in your case. We may use your PHI in reviewing and improving the quality, efficiency and cost of care. Since we are an integrated system, we may disclose your PHI to AHCCCS, health
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Division of Behavioral Health Services HIPAA Privacy Manual professionals and/or state agency workforce members involved in your care or for consultation purposes, Regional Behavioral Health Authorities, Tribal Regional Behavioral Health Authorities and their subcontracted providers, or ADHS workforce members, for similar purposes.
Uses and Disclosures of PHI Not Requiring Authorization: Unless otherwise prohibited by law, we may use or disclose your PHI without consent or authorization in the following circumstances:
When required by law: We may disclose PHI as required by state or federal law. Examples include reporting information about suspected abuse, neglect or domestic violence, or relating to suspected criminal activity, or in response to a court order or other legal process, judicial and administrative proceedings, and certain other law enforcement situations, to personal representatives, and workers compensation. We must also disclose PHI to authorities that monitor compliance with these privacy requirements.
For public health activities: We may disclose PHI when we are required to collect information for, and including situations pertaining to, the conduct of public health surveillance, public health investigations and public health interventions and the reporting of vital events such as birth or death to the public health authority.
For health oversight activities: We may disclose PHI to a health oversight agency for activities authorized by law. These oversight activities may include monitoring, audits, investigations, inspections, and licensure.
Relating to decedents: We may disclose PHI relating to an individual’s death including information to coroners, medical examiners or funeral directors, and to organ procurement organizations relating to organ, eye, or tissue donations or transplants.
For research purposes: In certain limited circumstances, we may disclose your PHI for research purposes. For example, a research project may involve the care and recovery of all enrolled persons who receive one medication for the same condition. All research projects are subject to a special approval process. We will obtain your written authorization if the researcher will use or disclose your behavioral health PHI.
To avert threat to health or safety: In order to avoid a serious threat to health or safety, we may disclose PHI as necessary to law enforcement or other persons who can reasonably prevent or lessen the threat of harm.
For specific government functions: We may disclose PHI of military personnel and veterans in certain situations. Other government related disclosures may include information disclosed to
Human Rights Committees, the Sexually Violent Persons Program, correctional facilities and other law enforcement custodial situations, to government benefit programs relating to eligibility and enrollment, and for national security reasons, such as protection of the President.
Uses and Disclosures Requiring You to which you have an Opportunity to Object: In the following situations, we may disclose a limited amount of your PHI, if we inform you about the disclosure in advance and you do not object, as long as the disclosure is not otherwise prohibited by law.
To families, friends or others involved in your care: We may share with these people information directly related to their involvement in your care, or payment for your care. We may also share PHI with these people to notify them about your location, general condition, or death.
Your Rights Regarding Your Protected Health Information. You have the following rights relating to your
Protected Health Information:
Right to Request Restrictions. You have the right to request that we restrict use or disclosure of your behavioral health information to carry out treatment, payment, health care operations, or communications with family, friends, or other individuals. We are not required to agree to a restriction. We cannot agree to limit uses/disclosures that are required by law.
Right to Request Conditions on Providing Confidential Communications. You have the right to request that we send communications that contain PHI by alternative means or to alternative locations. We must accommodate your request if it is reasonable and you clearly state that the disclosure of all or part of that information could endanger you.

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Right to Inspect and Copy. You have the right to inspect and copy behavioral health information that we maintain about you. Your request should be in writing. If copies are requested or if you agree to a summary or explanation of such information, we may charge a reasonable, cost-based fee for the costs of copying, including labor, postage; and preparation cost of an explanation or summary. We may deny your request to inspect and copy in certain circumstances as defined by law. Right to Request an Amendment. You have the right to request an amendment be made to your behavioral health information for as long as we maintain such record. The request must be in writing. Your request must include the reason or reasons that support your request. We may deny your request for an amendment if we determine that the record that is the subject of the request was not created by us, is not available for inspection as specified by law, or is accurate and complete. Right to Receive an Accounting of Disclosures. You have the right to receive an accounting of disclosures of your behavioral health information created by us. This does not include disclosures made: to carry out treatment, payment and health care operations; to you; to family, friends or others involved in your care; for national security or intelligence purposes; to correctional institutions or law enforcement officials; or disclosures made prior to the HIPAA compliance date of
April 14, 2003. Your first request for accounting in any 12-month period will be provided without charge. A reasonable, cost-based fee shall be imposed for each subsequent request.
You have the right to receive this notice: You have the right to receive a paper copy of this Notice and/or an electronic copy by email upon request. This information is also posted on our website at http://www.hs.state.az.us/bhs/index.htm. How to File a Complaint if You Believe Your Privacy Rights Have Been Violated
If you believe your privacy rights as set forth in this Notice have been violated, and you wish to complain, please write or contact one of the offices listed below:
Arizona Department of Health Services
Agency Privacy Officer
1740 West Adams-Room 101
Phoenix, Arizona 85007
Phone: [phone]
Or
Prior to July 1, 2003
Arizona Department of Health Services
Division of Behavioral Health Services
Manager for Grievance and Appeals
2122 East Highland Avenue, Suite 100
Phoenix Arizona 85016
Phone: [phone]

On or After July 1, 2003
Arizona Department of Health Services
Division of Behavioral Health Services
Manager for Grievance and Appeals th 150 N. 18 Avenue
Phoenix Arizona 85007
Phone: [phone]

You also may file a written complaint with the Secretary of the U.S. Department of Health and Human
Services. To ask for a complaint form, write to:
US Dept of Health & Human Services
Office of Civil Rights
50 United Nations Plaza - Room 322
San Francisco, CA 94102
Attn: Regional Manager
Or call for a complaint form at 1-800-368-1019
We will take no retaliatory action against you if you make such complaints.
Effective Date: This notice is effective on April 14, 2003

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REQUEST TO ACCESS PROTECTED HEALTH INFORMATION
Date: ______________________________________________
Name of Requester: ___________________________________
Date of birth: ________________________________________
REQUESTED ACCESS
I am requesting access to Protected Health Information about me that has been created or received by the Arizona
Department of Health Services/Division of Behavioral Health Services (ADHS/DBHS). I would like access to the following: Client Information System Record (check all the items that you want access to)
Client Data
Assessment Data
Enrollment Data
Claims or Encounter Data
TIME PERIOD AND FORM
I want access to my Protected Health Information that covers the following time period:
______________________________________________________________________________________
(Note: The time period must be no longer that six years and may not include dates before April 14, 2003.)

I want access in the following form:
Review only
Paper copy
Electronically (applicable to limited repositories of information)
Please send my copy to the following address (provide an e-mail address if you request your accounting electronically): ________________________________________________________.
I want to pick up my copy. Please call me at the following number when it is ready:
____________________________________.

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EXTENSIONS AND FEES
I understand that ADHS/DBHS must grant me the requested access within 30 days, unless the information is not readily available, in which case ADHS/DBHS shall grant me access in 60 days. ADHS/DBHS may extend these periods by an extra 30 days (or less) to prepare the information I have requested and shall notify me if this is necessary.
I understand that I am entitled to one free copy of my information in any 12-month period. I understand ADHS/DBHS may impose a reasonable fee for any additional request thereafter.
YOUR RIGHTS
For more information about your privacy rights, see the “Notice of Privacy Practices” available on our website at www.hs.state.az.us/bhs/index.htm or by sending a written request.
If you believe your privacy rights as set forth in this Notice have been violated, and you wish to complain, please write or contact one of the offices listed below:
Prior to July 1, 2003
Arizona Department of Health Services
Division of Behavioral Health Services
Manager for Grievance and Appeals
2122 East Highland Avenue, Suite 100
Phoenix Arizona 85016
Phone: [phone]

On or After July 1, 2003
Arizona Department of Health Services
Division of Behavioral Health Services
Manager for Grievance and Appeals
150 N. 18th Avenue
Phoenix Arizona 85007
Phone: [phone]

We will take no retaliatory action against you if you make such complaints.
SIGNATURE
Date: ______________________________________

Time: ________________________ AM/PM

Signature: _________________________________________________________
Enrolled person/Representative/Guardian
If signed by someone other than the Enrolled person, state your relationship to the enrolled person:
__________________________________________________________________

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NOTICE OF EXTENSION FOR PROVISION OF ACCESS TO
PROTECTED HEALTH INFORMATION
Date:

_____________________

Address:

______________________________________
______________________________________
______________________________________

Dear _______________:
On _______________, you requested that the Arizona Department of Health Services/Division of Behavioral Health
Services (ADHS/DBHS) provide you access to Protected Health Information within 30 days of the date of your request.
ADHS/DBHS requires a one-time extension of 30 days to prepare this information for you. The requested information will be accessible to you on ________________ [insert date].
ADHS/DBHS does not maintain the requested information on site and will provide you access within 60 days from the date of your request.
ADHS/DBHS did not create nor does it maintain the requested information. To request this information, please contact:
_______________________________________________________________________________
_______________________________________________________________________________
Other __________________________________________________________________________
For more information about your privacy rights, see the “Notice of Privacy Practices” available on our website at www.hs.state.az.us/bhs/index.htm or by sending a written request.
If you believe your privacy rights as set forth in this Notice have been violated, and you wish to complain, please write or contact one of the offices listed below:
Prior to July 1, 2003
Arizona Department of Health Services
Division of Behavioral Health Services
Manager for Grievance and Appeals
2122 East Highland Avenue, Suite 100
Phoenix Arizona 85016
Phone: [phone]

On or After July 1, 2003
Arizona Department of Health Services
Division of Behavioral Health Services
Manager for Grievance and Appeals
150 N. 18th Avenue
Phoenix Arizona 85007
Phone: [phone]

We will take no retaliatory action against you if you make such complaints.
Sincerely,

ADHS/DBHS
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RESPONSE TO REQUEST FOR ACCESS TO
PROTECTED HEALTH INFORMATION
Date:

__________________________________

Name:

__________________________________

Address:

__________________________________
__________________________________

RE:

Request for Access to Protected Health Information

Dear _____________________________:
We received your request for access to Protected Health Information dated _______________.
We need more time to process your request. We will send you the information you requested or provide an opportunity for you to review this information by ___________________ [insert date].
You did not provide all the information we needed on your form. Please complete the form and return it to us. You have already received one free copy of your Protected Health Information within the last 12 months.
Additional copies cost $ ________. Please send a check for this amount, made payable to the ADHS/DBHS at the address below.
Other __________________________________________________________________________
For more information about your privacy rights, see the “Notice of Privacy Practices” available on our website at www.hs.state.az.us/bhs/index.htm or by sending a written request.
If you believe your privacy rights as set forth in this Notice have been violated, and you wish to complain, please write or contact one of the offices listed below:
Prior to July 1, 2003
Arizona Department of Health Services
Division of Behavioral Health Services
Manager for Grievance and Appeals
2122 East Highland Avenue, Suite 100
Phoenix Arizona 85016
Phone: [phone]

On or After July 1, 2003
Arizona Department of Health Services
Division of Behavioral Health Services
Manager for Grievance and Appeals
150 N. 18th Avenue
Phoenix Arizona 85007
Phone: [phone]

We will take no retaliatory action against you if you make such complaints.
Sincerely,

ADHS/DBHS
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NOTICE OF DENIAL OF REQUEST FOR ACCESS TO
PROTECTED HEALTH INFORMATION
Date:

_____________________

Address:

______________________________________
______________________________________
______________________________________

Dear ________________:
On __________________, you requested that the Arizona Department of Health Services/Division of Behavioral
Health Services, (ADHS/DBHS) provide you access to Protected Health Information. ADHS/DBHS has determined that the release of this information is denied. This decision to deny access is subject to review pursuant to 45 CFR Part
164.524, except in the following circumstances:
The information contains psychotherapy notes
The information was compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding
The information is subject to the Clinical Laboratory Improvements Amendments of 1988
The information is subject to the Privacy Act (5 USC §552a) and the denial under the Privacy Act meets the requirements of law
The information was obtained for someone other than a health care provider under a promise of confidentiality and the access requested would be reasonably likely to reveal the source of the information
To file a request for review of your denial of access, please complete the enclosed form and return it to the address below. ADHS/DBHS will promptly refer your request to a designated reviewing official who shall determine in a reasonable period of time whether or not to deny the access. ADHS/DBHS will provide you written notice of our decision. For more information about your privacy rights, see the “Notice of Privacy Practices” available on our website at www.hs.state.az.us/bhs/index.htm or by sending a written request.
If you believe your privacy rights as set forth in this Notice have been violated, and you wish to complain, please write or contact one of the offices listed below:
Prior to July 1, 2003
Arizona Department of Health Services
Division of Behavioral Health Services
Manager for Grievance and Appeals
2122 East Highland Avenue, Suite 100
Phoenix Arizona 85016
Phone: [phone]

On or After July 1, 2003
Arizona Department of Health Services
Division of Behavioral Health Services
Manager for Grievance and Appeals
150 N. 18th Avenue
Phoenix Arizona 85007
Phone: [phone]

We will take no retaliatory action against you if you make such complaints.
Sincerely,

ADHS/DBHS
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REQUEST FOR REVIEW OF DENIAL OF REQUEST FOR ACCESS
TO PROTECTED HEALTH INFORMATION
ENROLLED PERSON INFORMATION
Date: ________________________________________________
Name: _______________________________________________
Date of birth: __________________________________________
REQUEST FOR REVIEW
On ____________________________ I requested access to protected information health for the above named enrolled person. I received written notification on __________________________ that my request for access was denied by the
Arizona Department of Health Services/Division of Behavioral Health Services, (ADHS/DBHS).
I am requesting a review of the ADHS/DBHS denial. I understand that the review will be conducted by a qualified reviewing official who is someone other than the party who denied access. I understand that a final administrative decision will be issued within a reasonable time of the receipt of this request by the ADHS/DBHS HIPAA Analyst.
SIGNATURE
Date: ______________________________________
Signature: _________________________________________________________
Enrolled person/Representative/Guardian
If signed by someone other that the Enrolled person, state your relationship to the enrolled person:
__________________________________________________________________
Witness: ___________________________________________________________

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NOTICE OF OUTCOME FOR DENIAL OF ACCESS REVIEW
Date:

_____________________

Address:

______________________________________
______________________________________
______________________________________

Dear ________________________:
On __________________________ you requested a review of the decision by the Arizona Department of Health
Services/Division of Behavioral Health Services, (ADHS/DBHS) to deny your request for access to Protected Health
Information. Your request was presented to a qualified reviewing official who determined the following:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
For more information about your privacy rights, see the “Notice of Privacy Practices” available on our website at www.hs.state.az.us/bhs/index.htm or by sending a written request.
If you believe your privacy rights as set forth in this Notice have been violated, and you wish to complain, please write or contact one of the offices listed below:
Prior to July 1, 2003
Arizona Department of Health Services
Division of Behavioral Health Services
Manager for Grievance and Appeals
2122 East Highland Avenue, Suite 100
Phoenix Arizona 85016
Phone: [phone]

On or After July 1, 2003
Arizona Department of Health Services
Division of Behavioral Health Services
Manager for Grievance and Appeals
150 N. 18th Avenue
Phoenix Arizona 85007
Phone: [phone]

We will take no retaliatory action against you if you make such complaints.
Sincerely,

ADHS/DBHS
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Appendix D: ADHS/DBHS Designated Record Set

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CEDAR Client File Format
File Header Record
Record
Column Name
Location
From To
1
1
*
Record_Type

Type

Size

Justify

Filler

Description/Comments

Char

01

Left

Spaces

Distinguishes header from data records.
Valid Value for a Header Record is “H”

2

3

*

RBHA_ID

Char

02

Justified None

Identifies RBHA submitting the file. The following are valid codes:
03 – The EXCEL Group
08 – Value Options
11 – Gila River Indian Community
14 – Navajo Nation
15 – NARBHA
23 – PGBHA
25 – Pascua Yaqui Tribe of Arizona
26 – CPSA Region 5
27 – CPSA Region 3

4

8

*

File_Name

Char

05

Left

Spaces

Indicates the name of the file.
Valid Values:
CLNT – Client Data

9

16

*

Transfer_Record_Co unt Numeric

08

Right

Zeroes

Indicates the total record count for the file.
This does not include Header record.

17

24

*

Transfer_Date

Numeric

08

None

Zeroes

This is the date the file was produced for transfer. CCYYMMDD and a valid date.

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25

30

31

189

19
0

190

*

Numeric

06

Right

Zeroes

Indicates the time the file was produced for transfer. HHMMSS and a 24-hour clock.

Filler
*

Transfer_Time

Char

159

Left

Spaces

This is the filler for the remainder of the fixed length record.

End-of_Record

Char

01

Left

None

The last position of each record has a tilde
(~) character.

CEDAR Client File Format
File Data Record
Record
Location
From To
1
1

2

2

Column Name

Type

Size

Justify

Filler

Description/Comments

*

Record_Type

Char

01

Left

Spaces

Distinguishes header from data records.
Valid Value for data records is “ “ (space) and
“H” for file header records.

*

Action_Code

Char

01

Left

Spaces

Indicates the record transaction type.
Valid Values:
A - Add; C - Correction;

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3

4

*

Submitting_RBHA_I
D

Char

02

Right

Zeroes

Contractor Identification Number. This is the
RBHA responsible for payment. The following are valid codes:
03 – The EXCEL Group
08 – Value Options
11 – Gila River Indian Community
14 – Navajo Nation
15 – NARBHA
23 – PGBHA
25 – Pascua Yaqui Tribe of Arizona
26 – CPSA Region 5
27 – CPSA Region 3

5

14

*

Client_ID

Char

10

Left

Spaces

Unique CIS 10-digit identification number that identifies a client.

15

22

*

Begin_Date

Numeric

08

None

None

23

32

**

SSNO

Char

10

Left

Spaces

33

41

**

AHCCCS_ID

Char

09

Left

Spaces

42

49

*

DOB

Numeric

08

None

Zeroes

The date the client intake was completed.
This date must be less than or equal to the current date.
CCYYMMDD and a valid date.
Client’s social security number. First nine digits is the SSN and the tenth digit is a SSN tie breaker. When entered, all digits are required. Not required when unavailable.
Indicates the client’s AHCCCS identifier.
This field is required for Title XIX eligible clients. Indicates the client’s date of birth.
CCYYMMDD and a valid date.

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50
50 *
Sex
CEDAR Client File Format
File Data Record
Record
Location
From To

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Column Name

Char

01

Left

Spaces

Valid Values: F - Female, M - Male

Type

Size

Justify

Filler

Description/Comments

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51

52

*

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Race_ID

Char

02

Left

None

Indicates client race.
Valid Values:
01 - White
02 - Black/African American
04 - Asian
05 - American Indian/Alaska Native
06 - Other
07 - Unknown
08 - Native Hawaiian/Pacific
Islander
CH - AK Chin
CO - Cocopah
CR - CRIT
FM - Fort Mohave
GR - Gila River Indian Community
HA - Havasupai
HO - Hopi
HU - Hualapai
KP - Kaibib Paiute
MY - Fort McDowell
NA - Navajo Nation
PY - Pascua Yaqui Tribe of Arizona
QU - Quechuan
SC - San Carlos Apache
SR - Salt River Pima
TA - Tonto Apache
TO - Tohono O’odham
WM - White Mountain
YA - Camp Verde Apache
YP - Yavapai Prescott Apache

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53

54

Ethnic_ID

Char

02

Left

None

Indicates client ethnicity.
Valid Values:
01 - Hispanic or Latino
02 - Not Hispanic or Latino

55
64 *
F_NM
65
65
M_NM
CEDAR Client File Format
File Data Record

Char
Char

10
01

Left
Left

Spaces
Spaces

Client’s first name.
Client’s Middle initial

Column Name

Type

Size

Justify

Filler

Description/Comments

*
*

L_NM
Address_Line_1
Address_Line_2

Char
Char
Char

15
25
25

Left
Left
Left

Spaces
Spaces
Spaces

Client’s last name.
Indicates client’s street address.
Additional address space.

*

City

Char

20

Left

Spaces

Indicates city of client’s address.

*

State

Char

02

Left

Spaces

Indicates state of client’s address.

*

Zip_Code

Char

09

Left

Spaces

Indicates zip code of client’s address.

Record
Location
From To
66
80
81 105
10 130
6
13 150
1
15 152
1
15 161
3

*

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16
2

163

*

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Residence_ID

Char

02

Left

Spaces

Place of residence
Valid Values:
01 – House or Apartment Without
Support
02 – Hotel
03 – Boarding Home
04 – Supervisory Care Home
05 – ASH
06 – Jail or Correctional facility
07 – Homeless/Shelter for Homeless
08 – Other
09 – Foster Home (CPS, DDD or APS)
10 – 24 hr Residential – Level 1
11 – 24 hr Residential – Level 2
12 – Nursing Home
13 – House or Apartment With Support
14 – Supervised Independent Living
15 – 24 hr Residential – Level 3
16 – Home With
Parent/Guardian/Relative/Friend
17 – CPS Relative Placement
18 – DES Group Home
19 – DES Emergency Shelter
20 – Therapeutic Foster Care
21 – Youth Living Independently

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CEDAR Client File Format
File Data Record
Record
Location
From To
16 165
4

16
6

Column Name
*

173

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Type

Size

Justify

Filler

Description/Comments

County_ID

Char

02

Left

Spaces

Begin_Date

Char

08

Left

Spaces

Indicates county of client’s address.
Valid Values:
01 - Apache
02 - Cochise
03 - Coconino
04 - Gila
05 - Graham
06 - Greenlee
07 - La Paz
08 - Maricopa
09 - Mohave
10 - Navajo
11 - Pima
12 - Pinal
13 - Santa Cruz
14 - Yavapai
15 - Yuma
16 - Out of State
If this field is 16, client state address must not be “AZ”.
Indicates the new or changed Enrollment
Date. This field only applies when there is an existing Enrollment record.
CCYYMMDD and a valid date.

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17
4

183

RBHA_Client_ID

Char

10

Left

Spaces

This is an optional field reserved for an additional Client ID assigned specifically by the RBHA.

18 189
Filler
Char
06
Left
Spaces
Reserved for Future Use
4
19 190 *
End_of_Record
Char
01
Left
None
The last position of each record has a tilde (~)
0
character.
Following the last record in the file is a carriage control line feed beginning in the first position.

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CEDAR Enrollment/Disenrollment File Format
File Header Record
Record
Location
From To
1
1

Column Name

Type

Size

Justify

Filler

Description/Comments

*

Record_Type

Char

01

Left

Spaces

Distinguishes header from data records.
Valid Value for a Header Record is “H”

2

3

*

RBHA_ID

Char

02

Justified

None

Identifies RBHA submitting the file. The following are valid codes:
03 – The EXCEL Group
08 – Value Options
11 – Gila River Indian Tribe
14 – Navajo Nation
15 – NARBHA
23 – PGBHA
25 – Pascua Yaqui
26 – CPSA Region 5
27 – CPSA Region 3

4

8

*

File_Name

Char

05

Left

Spaces

Indicates the name of the file.
Valid Values:
ENROL – Client Enrollment

9

16

*

Transfer_Record_C ount Numeric

08

Right

Zeroes

Indicates the total record count for the file.
This does not include Header record.

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CEDAR Enrollment/Disenrollment File Format
File Header Record
Record
Location
From To
17
24

25

30

31

79

80

80

Column Name

Type

Size

Justify

Filler

Description/Comments

*

Transfer_Date

Numeric

08

None

Zeroes

This is the date the file was produced for transfer. CCYYMMDD and a valid date.

*

Transfer_Time

Numeric

06

Right

Zeroes

Indicates the time the file was produced for transfer. HHMMSS and a 24 hour clock.

Record_Filler

Char

49

Left

Spaces

This is the filler for the remainder of the fixed length record.

End_of_Record

Char

01

Left

None

The last position of each record has a tilde (~) character. *

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CEDAR Enrollment/Disenrollment File Format
File Data Record
Record
Column Name
Location
From To
1
1
*
Record_Type

Type

Size

Justify

Filler

Description/Comments

Char

01

Left

Spaces

Distinguishes header from data records.
Valid Value for data records is “ ” (space) and
“H” for file header records.
Indicates the record transaction type.
Valid Values:
A - Add; C - Change
Contractor Identification Number. This is the
RBHA with whom the client is enrolled. The following are valid codes:
03 – The EXCEL Group
08 – Value OptionsCOMCARE
11 – Gila River Indian Tribe
14 – Navajo Nation
15 – NARBHA
23 – PGBHA
25 – Pascua Yaqui
26 – CPSA Region 5
27 – CPSA Region 3

2

2

*

Action_Code

Char

01

Left

Spaces

3

4

*

RBHA_ID

Char

02

Left

Zeroes

5

14

*

Client_ID

Char

10

Left

Spaces

15

22

*

Enrollment_Date

Char

08

None

Spaces

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
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Unique CIS 10-digit identification number that identifies a client.
This is the date that the client was accepted for enrollment by the RBHA.
CCYYMMDD
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CEDAR Enrollment/Disenrollment File Format
File Data Record
Record
Column Name
Location
From To
23
30 *
Referral_Date

Type

Size

Justify

Filler

Description/Comments

Char

08

None

Spaces

31

32

*

Pri_Pres_Problem_I
D

Char

02

None

None

This is the date that the client first requested an appointment.
CCYYMMDD
Primary Problem
Valid assessment problem values:
01 - Suicidal/Self Harm/Danger to Self
02 - Victim of Abuse/Violence
03 - Anxiety/Stress
04 - Depression or Mood Disorder
05 - Psychotic Symptoms
07 - Alcohol Abuse
08 - Other Drug Abuse
10 - Relationship/Interpersonal
11 - Role Performance
13 - Unable to Care for Self
14 - Other
16 - Parent/Child Problem
17 - Disruptive
18 - Assaultive/Homicidal/Danger To
Others

33

36

*

Sub_Contr_ID

Char

04

Left

Spaces

37

39

*

Facility_ID

Char

03

Left

Spaces

ADHS/DBHS
HIPAA Privacy Manual
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Identification of the Provider who obtains the
Enrollment/Disenrollment information.
Identification of the Facility where information for the Enrollment/Disenrollment information was obtained.
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CEDAR Enrollment/Disenrollment File Format
File Data Record
Record
Column Name
Location
From To
40
41 *
Referral_Source_ID

Type

Size

Justify

Filler

Description/Comments

Char

02

Left

Spaces

Indicates the entity type of the transfer or referral source.
Valid values:
01 – Self, Family, Friend
03 – Behavioral Health Provider
06 – Social Service Agency
07 – School /ADE
08 – Employer /EAP
11 – General Medical Provider
14 – Shelter for Homeless
15 – Veterans Administration
16 – Indian Health Service
18 – AZ Office of Courts / Juvenile Probation Office
19 – Other
20 – ADOC - AZ Department of Corrections
22 – DES/ACYF - Department of Economic Security /
Assistance to Children, Youth, & Families
26 – Adult Probation/Court
31 – Nursing Home
32 – DES/DD Department of Economic Security /
Developmental Disabilities
33 – DES/DVR Department of Economic Security /
Vocational Rehabilitation
34 – AZ Department of Juvenile Corrections

42

49

**

ADHS/DBHS
HIPAA Privacy Manual
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Disenroll_Date

Char

08

Left

Spaces

The date the client is closed out or disenrolled. A disenrollment may be dated the same as the Enrollment.
CCYYMMDD and a valid date.

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CEDAR Enrollment/Disenrollment File Format
File Data Record
Record
Column Name
Type
Location
From To
50
51 ** Reason_Disenroll_ID Char

Size

Justify

Filler

Description/Comments

02

Left

Spaces

Indicates the reason for the disenrollment.
Valid Values:
01 – Treatment completed
02 – Change in
Eligibility/Entitlement
Information.
03 – Client Declined Further Service
04 – Lack of contact
06 – Incarceration
07 – Death
08 – Moved out of area
09 – Inter RBHA Transfer
10 – One Time Consultation
When a disenrollment date is present, this field is required.

52

01

None

None

53
80

52

79
80

**

*

Resolution_Pres_Pro b_ID Char

Filler
End-of_Record

Char
Char

27
01

Left
Left

Spaces
None

1 – Full resolution of problem
2 – Partial resolution of problem
3 – No resolution of problem
When a disenrollment date is present, this field is required.
Reserved For Future Use.
The last position of each record has a tilde (~) character. Following the last record in the file is a carriage control line feed beginning in the first position.
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CEDAR Assessment File Format
File Header Record
Record
Column Name
Location
From To
1
1
*
Record_Type

Type

Size Justify

Filler

Description/Comments

Char

01

Left

Spaces

Distinguishes header from data records.
Valid Value for a Header Record is “H”

2

3

*

RBHA_ID

Char

02

Justified

None

Identifies RBHA submitting the file. The following are valid codes:
03 – The EXCEL Group
08 – Value Options
11 – Gila River Indian Community
14 – Navajo Nation
15 – NARBHA
23 – PGBHA
25 – Pascua Yaqui Tribe of Arizona
26 – CPSA Region 5
27 – CPSA Region 3

4

8

*

File_Name

Char

05

Left

Spaces

9

16

*

Transfer_Record_Count

Numeri c 08

Right

Zeroes

Indicates the name of the file.
Valid Values:
ASSMT – Assessment
Indicates the total record count for the file. This does not include Header record.

17

24

*

Transfer_Date

Numeri c 08

None

Zeroes

ADHS/DBHS
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This is the date the file was produced for transfer.
CCYYMMDD and a valid date.

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CEDAR Assessment File Format
File Header Record
Record
Column Name
Location
From To
25
30 *
Transfer_Time
31
20
0

199
200

*

ADHS/DBHS
HIPAA Privacy Manual
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April 14, 2003

Record_Filler
End_of_Record

Type

Size Justify

Filler

Description/Comments

Numeri c 06

Right

Zeroes

Indicates the time the file was produced for transfer.
HHMMSS and a 24 hour clock.

Char
Char

169
01

Left
Left

Spaces
None

This is the filler for the remainder of the fixed length record.
The last position of each record has a tilde (~) character.

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CEDAR Assessment File Format
File Data Record
Record
Column Name
Location
From
To
1
1
* Record_Type
#

Type

Size Justify

Filler

Description/Comments

Char

01

Left

Spaces

Distinguishes header from data records.
Valid Value for a Header Record is “H”

2

2

*
#

Action_Code

Char

01

Left

Spaces

Indicates the record transaction type.
Valid Values
A – Add, C – Change

3

4

*
#

RBHA_ID

Char

02

Justified

None

Contractor Identification Number. This is the same as the RBHA ID.
03 – The EXCEL Group
08 – Value Options
11 – Gila River Indian Community
14 – Navajo Nation
15 – NARBHA
23 – PGBHA
25 – Pascua Yaqui Tribe of Arizona
26 – CPSA Region 5
27 – CPSA Region 3

5

14

*
#

Client_ID

Char

10

Left

Spaces

Unique CIS 10-digit identification number that identifies a client.

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CEDAR Assessment File Format
File Data Record
Record
Column Name
Location
From
To
15 22
* Assess_Date
#

Type

Size Justify

Filler

Description/Comments

Date

08

Justified

None

This is the date of the Assessment. This date must not be less than the enrollment date.
CCYYMMDD and a valid date.

01

Justified

None

Assessment Type indicates the type of assessment submitted. B – Brief
C – Comprehensive

23

23

*
#

Assess_Type

Char

24

24

*
#

Interval_ID

Numeric 01

Right

Zeroes

Assessment Interval indicates the time period of the assessment. Valid Values:
1 – Enrollment
2 – During Treatment
3 – Disenrollment
4 – Follow-up after closure/disenrollment

25

30

Health_Plan_ID

Char

Left

Spaces

Indicates the AHCCCS issued health plan identifier.
This is a six digit numeric field that is required for
Title XIX eligible clients. This must be present when an AHCCCS ID is present in this record.

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CEDAR Assessment File Format
File Data Record
Record
Column Name
Location
From
To
31 31
* CMD_Arthritis

Char

01

Justified

None

Chronic Medical Disorder Arthritis
Valid Values: Y or N

32

32

*

CMD_Asthma

Char

01

Justified

None

Chronic Medical Disorder Asthma / COPD
Valid Values: Y or N

33

33

*

CMD_Cancer

Char

01

Justified

None

Chronic Medical Disorder Cancer
Valid Values: Y or N

34

34

*

CMD_Diabetes

Char

01

Justified

None

Chronic Medical Disorder Diabetes
Valid Values: Y or N

35

35

*

CMD_Head_Injury

Char

01

Justified

None

Chronic Medical Disorder Head Injury
Valid Values: Y or N

36

36

*

CMD_Headaches

Char

01

Justified

None

Chronic Medical Disorder Headaches
Valid Values: Y or N

37

37

*

CMD_High_Blood_Pressur Char e 01

Justified

None

Chronic Medical Disorder High Blood Pressure
Valid Values: Y or N

38

38

*

CMD_Other

01

Justified

None

Chronic Medical Disorder Other
Valid Values: Y or N

ADHS/DBHS
HIPAA Privacy Manual
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Type

Char

Size Justify

Filler

Description/Comments

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CEDAR Assessment File Format
File Data Record
Record
Column Name
Type
Location
From
To
39 39
* CMD_Other_Heart_Disease Char

01

Justified

None

Chronic Medical Disorder Other Heart/
CARDIOVASCULAR Disease
Valid Values: Y or N

40

01

Justified

None

Chronic Medical Disorder Seizures
Valid Values: Y or N

40

*

ADHS/DBHS
HIPAA Privacy Manual
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CMD_Seizures

Char

Size Justify

Filler

Description/Comments

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CEDAR Assessment File Format
File Data Record
Record
Column Name
Location
From
To
41 44
* Substance_1

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Type
Char

Size Justify
04

Justified

Filler
None

Description/Comments
Drug Type Primary is the Substance Use Primary Drug Type
Valid Values:
0001 - None
0201 - Alcohol
0202 - Tobacco
0302 - Cocaine
0401 - Marijuana
0501 - Heroin/Morphine
0601 - Methadone
0700 - Other Narcotics
0801 - PCP
0902 - Other Hallucinogens
1001 - Methamphetamine
1201 - Other Stimulants
1308 - Benzodiazepines
1504 - Barbiturates
1605 - Other Sedatives
1703 - Inhalants
2002 - Other Drugs

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CEDAR Assessment File Format
File Data Record
Record
Column Name
Location
From
To
45 45
* Drug_Freq_1

Char

01

Justified

None

Drug Frequency Primary is the Substance Use Primary
Drug Frequency Usage. When Drug-Type-1 - 0001,
Drug-Freq-1 must - 1.
Valid Values
1 - None during past month
2 - 1 - 3 times past month
3 - 1 - 2 times weekly
4 - 3 - 6 times weekly
5 - Daily
6 - 2 - 3 times a day
7 - More than 3 times a day

46

Char

01

Left

Spaces

Drug Route Primary is the primary route of administration.
When Drug-Type-1 - 0001, Drug-Route-1 must be blank.

46

** Drug_Route_1

Type

Size Justify

Filler

Description/Comments

Valid Route Values:
1 - Oral
2 - Smoking
3 - Inhalation
4 - Injection
5 - Other

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CEDAR Assessment File Format
File Data Record
Record
Column Name
Location
From
To
47 48 ** Age_First_Use_1

Type
Char

Size Justify
02

Left

Filler
Spaces

Description/Comments
Age of First Use for the Primary Substance.
When Drug-Type-1 - 0001, Drug-Age-1 must be blank
Valid values are 00 - 99

49

52

Substance_2

Char

04

Left

Spaces

Drug Type Secondary is the Substance Use Secondary Drug
Type
See Drug-Type-1 for valid values.

53

53

Drug_Freq_2

Char

01

Left

Spaces

Drug Frequency Secondary is the Substance Use Secondary
Drug
See Drug-Freq-1 for valid values.

54

54

Drug_Route_2

Char

01

Left

Spaces

55

56

Age_First_Use_2

Char

02

Left

Spaces

Drug Route Secondary is the primary route of administration
See Drug-Rte-1 for valid values.
Age of First Use for the Secondary Substance.

57

60

Substance_3

Char

04

Left

Spaces

Drug Type Tertiary is the Substance Use Tertiary Drug Type
See Drug-Type-1 for valid values.

61

61

Drug_Freq_3

Char

01

Left

Spaces

Drug Frequency Tertiary is the Substance Use Tertiary Drug
See Drug-Freq-1 for valid values.

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CEDAR Assessment File Format
File Data Record
Record
Column Name
Location
From
To
62 62
Drug_Route_3

Char

01

Left

Spaces

Drug Route Tertiary is the primary route of administration
See Drug-Rte-1 for valid values.

63

64

Age_First_Use_3

Char

02

Left

Spaces

Age of First Use for the Tertiary Substance.

65

65

Educational_Stat_ID

Char

01

Justified

None

Educational-Status
Valid Values:
1 - Attending School Full Time
2 - Attending School Part Time
3 - Not in School

*

ADHS/DBHS
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Version 1.0
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Type

Size Justify

Filler

Description/Comments

82

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CEDAR Assessment File Format
File Data Record
Record
Column Name
Location
From
To
66 67
* Employment_Stat_ID

Type
Char

Size Justify
02

Filler

Justified

None

Employment/Rehabilitation - status
Valid Values:
01 – Employed Full Time Without Support
02 – Employed Part Time Without Supports
03 – Employed Full Time With Supports
04 – Employed Part Time With Supports
05 – Transitional Employment
06 – Community-Based Work
07 – Facility-Based Work Adjustment/ Work Activities
09 – Sheltered Employment
10 – Education/Training Without Supports
11 – Education/Training With Supports
12 – Psychosocial Rehabilitation
13 – Social Drop-In/Recreational Activities
14 – Volunteer
15 – Other Community Activities
16 – Not Currently in Vocational Educational Activities
See ALFA Scale
Valid Values: 01 - 50
See ALFA Scale
Valid Values: 01 - 50
See ALFA Scale
Valid Values: 01 - 50

68

69

*

Fam_Livng_Situatn_Funct Numeric 02

Right

Zeroes

70

71

*

Right

Zeroes

72

73

*

Feeling_Affect_Mood_Func Numeric 02 t Interprsnl_Rlns_Funct
Numeric 02

Right

Zeroes

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HIPAA Privacy Manual
Version 1.0
April 14, 2003

Description/Comments

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Division of Behavioral Health Services HIPAA Privacy Manual
CEDAR Assessment File Format
File Data Record
Record
Column Name
Location
From
To
74 75
* Medical_Physical_Funct

Numeric 02

76

77

*

Role_Performnce_Funct

78

79

80

Filler

Description/Comments

Right

Zeroes

Numeric 02

Right

Zeroes

*

SelfCare_Bas_Needs_Funct Numeric 02

Right

Zeroes

81

*

Socio_Legal_Funct

Numeric 02

Right

Zeroes

82

83

*

Substance_Abuse_Funct

Numeric 02

Right

Zeroes

84

85

*

Think_Mntl_Proc_Funct

Numeric 02

Right

Zeroes

See ALFA Scale
Valid Values: 01 - 50
See ALFA Scale
Valid Values: 01 - 50
See ALFA Scale
Valid Values: 01 - 50
See ALFA Scale
Valid Values: 01 - 50
See ALFA Scale
Valid Values: 01 - 50
See ALFA Scale
Valid Values: 01 - 50

86

88

*

Household_Income

Numeric 03

Right

Zeroes

Household Income is a 3 digit field indicating, in thousands, the client’s annual family income. The right-most 3 zeroes are pre-filled to denote thousands.
Amounts must be in the range 000 - 999. When IS-NoIncome - “Y”, Household Income must - 000

89

90

*

Household_Size

Numeric 02

Right

Zeroes

Household Size indicates the number of people, including the client who live at the client’s address.

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Type

Size Justify

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Division of Behavioral Health Services HIPAA Privacy Manual
CEDAR Assessment File Format
File Data Record
Record
Column Name
Location
From
To
91 91
* IS_AFDC

Char

01

Justified

None

INCOME SOURCE - AFDC / TANF
Valid Values: Y or N

92

92

*

IS_Employment

Char

01

Justified

None

INCOME SOURCE - Employment
Valid Values: Y or N

93

93

*

IS_Family

Char

01

Justified

None

INCOME SOURCE - Family
Valid Values: Y or N

94

94

*

IS_Food_Stamps

Char

01

Justified

None

INCOME SOURCE - Food-Stamps
Valid Values: Y or N

95

95

*

IS_Gen_Assist

Char

01

Justified

None

INCOME SOURCE - Gen-Assist
Valid Values: Y or N

96

96

*

IS_No_Income

Char

01

Justified

None

INCOME SOURCE - No-Income
Valid Values: Y or N

97

97

*

IS_Other

Char

01

Justified

None

INCOME SOURCE - Other
Valid Values: Y or N

98

98

*

IS_Retirement

Char

01

Justified

None

INCOME SOURCE - Retirement
Valid Values: Y or N

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Type

Size Justify

Filler

Description/Comments

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CEDAR Assessment File Format
File Data Record
Record
Column Name
Location
From
To
99 99
* IS_SSA

Char

01

Justified

None

INCOME SOURCE - Social Security
Valid Values: Y or N

100 100

*

IS_SSDI

Char

01

Justified

None

INCOME SOURCE - SSDI
Valid Values: Y or N

101 101

*

IS_SSI

Char

01

Justified

None

INCOME SOURCE - SSI
Valid Values: Y or N

102 102

*

IS_Unemployment

Char

01

Justified

None

INCOME SOURCE - Unemployment
Valid Values: Y or N

103 103

*

IS_Veteran_Comp

Char

01

Justified

None

INCOME SOURCE - Veteran Comp
Valid Values: Y or N

104 104

*
#

Legal_Stat_ID

Char

01

Justified

None

Indicates legal status under which a client enters the facility or service.
Valid Values:
1 – Voluntary
6 – Civil Court Order
7 – DUI Court Order
8 – Other Criminal Court Order

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Type

Size Justify

Filler

Description/Comments

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CEDAR Assessment File Format
File Data Record
Record
Column Name
Location
From
To
105 105 * Marital_Stat_ID

Char

106 107

*

Nbr_of_Arrests

108 108

*

109 109

Type

Size Justify

Description/Comments

Justified

None

Indicates client’s marital status. Valid Values:
1 - Never Married
2 - Married
3 - Divorced
4 - Widowed
5 - Separated

Numeric 02

Right

Zeroes

Number of Arrests indicate the number of arrests during the past 6 months. Valid Values 00 - 99.

OA_ADJC

Char

01

Justified

None

*

OA_AOC_JPO

Char

01

Justified

None

110 110

*

OA_Adult_Probation_Court Char

01

Justified

None

111 111

*

OA_DES_ACYF

Char

01

Justified

None

112 112

*

OA_DES_DDD

Char

01

Justified

None

113 113

*

OA_DES_DVR

Char

01

Justified

None

114 114

*

OA_ADC

Char

01

Justified

None

OTHER AGENCY - ADJC
Valid Values - Y or N
OTHER AGENCY - AOC-JPO
Valid Values - Y or N
OTHER AGENCY - Adult-Probation-Court
Valid Values - Y or N
OTHER AGENCY - DES-ACYF
Valid Values - Y or N
OTHER AGENCY - DES-DDD
Valid Values - Y or N
OTHER AGENCY - DES-DVR
Valid Values - Y or N
OTHER AGENCY - ADC
Valid Values - Y or N

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

01

Filler

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Division of Behavioral Health Services HIPAA Privacy Manual
CEDAR Assessment File Format
File Data Record
Record
Column Name
Location
From
To
115 115 * SF_1

Numeric 01

Justified

Spaces

Valid Values:
0 - Not Assessed
1 - Excellent
2 - Very good
3 - Good
4 - Fair
5 - Poor

116 116

*

SF_2

Numeric 01

Justified

Spaces

Valid Values:
0 - Not Assessed
1 - Yes, limited a lot
2 - Yes, limited a little
3 - No, not limited at all

117 117

*

SF_3

Numeric 01

Justified

Spaces

Valid Values:
0 - Not Assessed
1 - Yes, limited a lot
2 - Yes, limited a little
3 - No, not limited at all

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Type

Size Justify

Filler

Description/Comments

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Division of Behavioral Health Services HIPAA Privacy Manual
CEDAR Assessment File Format
File Data Record
Record
Column Name
Location
From
To
118 118 * SF_4

Numeric 01

Justified

Spaces

Valid Values:
0 - Not Assessed
1 - Yes
2 - No

119 119

*

SF_5

Numeric 01

Justified

Spaces

120 120

*

SF_6

Numeric 01

Justified

Spaces

121 121

*

SF_7

Numeric 01

Justified

Spaces

Valid Values:
0 - Not Assessed
1 - Yes
2 - No
Valid Values:
0 - Not Assessed
1 - Yes
2 - No
Valid Values:
0 - Not Assessed
1 - Yes
2 - No

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Type

Size Justify

Filler

Description/Comments

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Division of Behavioral Health Services HIPAA Privacy Manual
CEDAR Assessment File Format
File Data Record
Record
Column Name
Location
From
To
122 122 * SF_8

Numeric 01

Justified

Spaces

Valid Values:
0 - Not Assessed
1 - Not at all
2 - A little bit
3 - Moderately
4 - Quite a bit
5 - Extremely

123 123

Numeric 01

Justified

Spaces

Valid Values:
0 - Not Assessed
1 - All of the time
2 - Most of the time
3 - A good bit of the time
4 - Some of the time
5 - A little of the time
6 - None of the time

*

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

SF_9

Type

Size Justify

Filler

Description/Comments

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Division of Behavioral Health Services HIPAA Privacy Manual
CEDAR Assessment File Format
File Data Record
Record
Column Name
Location
From
To
124 124 * SF_10

Numeric 01

Justified

Spaces

Valid Values:
0 - Not Assessed
1 - All of the time
2 - Most of the time
3 - A good bit of the time
4 - Some of the time
5 - A little of the time
6 - None of the time

125 125

Numeric 01

Justified

Spaces

Valid Values:
0 - Not Assessed
1 - All of the time
2 - Most of the time
3 - A good bit of the time
4 - Some of the time
5 - A little of the time
6 - None of the time

*

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

SF_11

Type

Size Justify

Filler

Description/Comments

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Division of Behavioral Health Services HIPAA Privacy Manual
CEDAR Assessment File Format
File Data Record
Record
Column Name
Location
From
To
126 126 * SF_12

Numeric 01

127 127
128 128
129 129
130 130
131 131
132 132
133 133

Type

Size Justify

Filler

Description/Comments

Justified

Spaces

Valid Values:
0 - Not Assessed
1 - All of the time
2 - Most of the time
3 - Some of the time
4 - A little of the time
5 - None of the time
SPECIAL POPULATIONS - Intravenous Drug user
Valid Values - Y or N
SPECIAL POPULATIONS - Pregnant Woman
Valid Values - Y or N
SPECIAL POPULATIONS – Women with Dependent
Children
Valid Values – Y or N
SPECIAL POPULATIONS - SMI-SED
Valid Values - Y or N
SPECIAL POPULATIONS - SEH (Special ED)
Valid Values - Y or N
SPECIAL POPULATIONS - Drug
Valid Values - Y or N
SPECIAL POPULATIONS - Alcohol
Valid Values - Y or N

*
#
*
#
*
#

SP_IV_Drug_Flag

Char

01

Justified

None

SP_Pregnant_Flag

Char

01

Justified

None

SP_Women_Dep_Children_ Char
Flag

01

Justified

None

*
#
*
#
*
#
*
#

SP_SMI_SED_Flag

Char

01

Justified

None

SP_Special_ED_Flag

Char

01

Justified

None

SP_Drug_Flag

Char

01

Justified

None

SP_Alcohol_Flag

Char

01

Justified

None

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Version 1.0
April 14, 2003

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Division of Behavioral Health Services HIPAA Privacy Manual
CEDAR Assessment File Format
File Data Record
Record
Column Name
Type
Location
From
To
134 134 * SP_Gen_Mental_Health_Fl Char
# ag
135 136 * SP_Other_ID_Flag
Char
#

137 137

*
#

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

RBHA_Fund_Source_ID

Char

Size Justify

Filler

01

Justified

None

02

Justified

None

01

Justified

None

Description/Comments
SPECIAL POPULATIONS - General Mental Health
Valid Values - Y or N
SPECIAL POPULATIONS - Other
Valid Values:
00 – None
C1 – COOL
C2 – AOC Paid
C3 – Model Court
C4 – Gambling
C5 – Tobacco Tax Paid
C6 – HB2003
C7 – SB1280
KP – 300 Kids
Indicates the program that the client is assigned at the time of intake by the RBHA.
Valid Values:
M - Adult Mental Health Services
A - Alcohol Abuse Treatment
D - Drug Abuse Treatment
S - SMI Services
C - Children’s Services
V - Domestic Violence
P - Prevention/Early Intervention

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Arizona Department of Health Services
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CEDAR Assessment File Format
File Data Record
Record
Column Name
Location
From
To
138 139 * Educ_Years

Numeric 02

Right

Zeroes

School Years Completed indicate the number of formal school years completed. Valid values are 00 - 99.

140 145

Axis_I_1

Char

06

Justified

Spaces

Valid DSM Code

Axis_I_2

Char

06

Justified

Spaces

Valid DSM Code

Axis_II_1

Char

06

Justified

Spaces

Valid DSM Code

158 163

Axis_II_2

Char

06

Justified

Spaces

Valid DSM Code

164 169

Axis_III_1

Char

06

Left

Spaces

Valid DSM Code

*

146 151
152 157

*

Type

Size Justify

Filler

Description/Comments

170 173

*
#

Sub_Contr_ID

Char

04

Left

Spaces

Indicates the Provider ID who performed the Assessment.
This must be a valid ADHS/DBHS provider.

174 176

*
#

Facility_ID

Char

03

Left

Spaces

Indicates the Facility where Assessment was performed.
This must be a valid ADHS/DBHS provider.

177 178

CGI_Efficacy_Index

Char

02

Justified

None

CGI Scale

179 179
180 180

CGI_Global_Improvement Char
CGI_Severity_of_Illness
Char

01
01

Justified
Justified

None
None

CGI Scale
CGI Scale

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HIPAA Privacy Manual
Version 1.0
April 14, 2003

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Division of Behavioral Health Services HIPAA Privacy Manual
CEDAR Assessment File Format
File Data Record
Record
Column Name
Location
From
To
181 188
First_Created_Date

Char

08

Left

Spaces

189 190

Char

02

Left

Spaces

** TPL_ID
#

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Type

Size Justify

Filler

Description/Comments
Indicates the new or changed enrollment date. This field only applies when there is an existing enrollment date.
CCYYMMDD
Indicates the first source of payment for mental health services other than the State or AHCCCS. Leave blank when the State or AHCCCS are the only fund sources.
Valid Values:
01 - Self Pay
02 - Medicare
03 - Other Government
04 - Other Insurance
09 - Other

95

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
CEDAR Assessment File Format
File Data Record
Record
Column Name
Location
From
To
191 191 ** Med_Insurance_ID
#

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Type
Char

Size Justify
01

Left

Filler
Spaces

Description/Comments
This field indicates that the client has other insurance coverage for medical benefits.
Valid Values:
1 - Medicare
2 - AHCCCS
3 - Private (is defined as coverage entirely provided by the client)
4 - CHAMPUS/VA
5 - Other (is defined as from an employee contribution plan provided by an employer)
6 - Blue Cross
7 - HMO
9 - None

96

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CEDAR Assessment File Format
File Data Record
Record
Column Name
Location
From
To
192 193 * Primary_Residence

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Type
Char

Size Justify
02

Left

Filler
Spaces

Description/Comments
Place of residence
Valid Values:
01 – House or Apartment Without Support
02 – Hotel
03 – Boarding Home
04 – Supervisory Care Home
05 – ASH
06 – Jail or Correctional facility
07 – Homeless/Shelter for Homeless
08 – Other
09 – Foster Home (CPS, DDD or APS)
10 – 24 hr Residential – Level 1
11 – 24 hr Residential – Level 2
12 – Nursing Home
13 – House or Apartment With Support
14 – Supervised Independent Living
15 – 24 hr Residential – Level 3
16 – Home With Parent/Guardian/Relative/Friend
17 – CPS Relative Placement
18 – DES Group Home
19 – DES Emergency Shelter
20 – Therapeutic Foster Care
21 – Youth Living Independently

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Division of Behavioral Health Services HIPAA Privacy Manual
CEDAR Assessment File Format
File Data Record
Record
Column Name
Location
From
To
194 199
Filler
200 200 * End_of_Record

Type
Char
Char

Size Justify
07
01

Left
Left

Filler
Spaces
None

Description/Comments
Reserved for future use.
The last position of each record has a tilde (~) character.

Following the last record in the file is a carriage control line feed beginning in the first position.

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Version 1.0
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CIS Database Tables
Column_I

Column_Name

Table Name:
AHCCCS_CAPITATION_ROSTER
1
TRANSACTION_NBR
2
AHCCCS_ID
3
MHS_CAT
4
CATEGORY_CODE
5
TRIBAL_CODE
6
CONTRACT_TYPE
7
CAPITATION_AMOUNT
8
NUMBER_OF_DAYS_COVERED
9
PAYMENT_FROM_DATE
10
PAYMENT_TO_DATE
11
DAILY_ACTION_CODE
12
INVOICE_NBR
13
CHANGE_CONTROL_DATE
14
CHANGE_CONTROL_PROGRAM
15
CONTR_ID
16
CLIENT_ID
17
STATUS
18
ADM_CAP_AMT
19
CASE_MGT_CAP_AMT
20
CASE_SERVICE_CAP_AMT
21
NON_CASE_SERVICE_CAP_AMT
22
STATE_MATCH_AMOUNT
23
ADM_RESERVE_AMOUNT
24
PROCESS_DATE
25
BUSINESS_MONTH
Table Name:
AHCCCS_DAILY_MATCH_PERCENTAGE
1
CATEGORY_CODE
2
TRIBAL_CODE
3
CONTRACT_TYPE
4
RATE_BEG_DATE
5
RATE_END_DATE
6
MONTH_BEG_DATE
7
MONTH_END_DATE
8
DAILY_CAPITATION_AMOUNT

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type

Data Length Null?

NUMBER
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
NUMBER
NUMBER
DATE
DATE
VARCHAR2
VARCHAR2
DATE
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
DATE
NUMBER

9,0
9
1
2
2
1
7,2
3,0
7
7
2
9
7
6
2
10
2
7,2
7,2
7,2
7,2
7,2
7,2
7
6,0

N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
Y
Y
Y
Y
Y
Y
Y
Y

VARCHAR2
VARCHAR2
VARCHAR2
DATE
DATE
DATE
DATE
NUMBER

2
2
1
7
7
7
7
9,4

N
N
N
N
N
N
N
Y

99

Arizona Department of Health Services
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Column_I

Column_Name

9
FEDERAL_PORTION
10
STATE_MATCH_PORTION
11
ADHS_RESERVE_AMOUNT
Table Name:
AHCCCS_ELIG_CHG
1
AHCCCS_ID
2
CONTR_ID
3
CLIENT_ID
4
START_DATE
5
PRIOR_START_DATE
6
CHANGE_CONTROL_DATE
7
CHANGE_CONTROL_PGM
8
CHANGE_CONTROL_USER_ID
9
ORIG_CIS_ADD_DATE
Table Name:
AHCCCS_ELIG_CHG_LOG
1
CLIENT_ID
2
CONTR_ID
3
AHCCCS_ID
4
START_DT
5
END_DT
6
MHS_CAT
7
CAPITATION_CODE
8
CONTRACT_TYPE
9
CHANGE_CONTROL_DATE
10
CHANGE_CONTROL_USER_ID
11
CHANGE_CONTROL_PGM
12
CIS_ADD_DATE
13
OLD_START_DT
14
OLD_END_DT
15
OLD_MHS_CAT
16
OLD_CAPITATION_CODE
17
OLD_CONTRACT_TYPE
18
OLD_CHANGE_CONTROL_DATE
19
OLD_CHANGE_CONTROL_USER_ID
20
OLD_CHANGE_CONTROL_PGM
21
OLD_CIS_ADD_DATE
Table Name:
AHCCCS_ELIG_EOM
1
AHCCCS_ID
2
START_DT

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type

Data Length Null?

NUMBER
NUMBER
NUMBER

9,4
9,4
9,4

Y
Y
Y

VARCHAR2
VARCHAR2
VARCHAR2
DATE
DATE
DATE
VARCHAR2
VARCHAR2
DATE

9
2
10
7
7
7
8
8
7

N
N
N
Y
N
N
N
Y
Y

VARCHAR2
VARCHAR2
VARCHAR2
DATE
DATE
VARCHAR2
VARCHAR2
VARCHAR2
DATE
VARCHAR2
VARCHAR2
DATE
DATE
DATE
VARCHAR2
VARCHAR2
VARCHAR2
DATE
VARCHAR2
VARCHAR2
DATE

10
2
9
7
7
1
4
1
7
30
8
7
7
7
1
4
1
7
30
8
7

N
N
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

VARCHAR2
DATE

9
7

N
N

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Arizona Department of Health Services
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Column_I

Column_Name

3
END_DT
4
CLIENT_ID
5
MHS_CAT
6
CAPITATION_CODE
7
CONTRACT_TYPE
8
CHANGE_CONTROL_DATE
9
CHANGE_CONTROL_USER_ID
10
CIS_ADD_DATE
11
CHANGE_CONTROL_PGM
12
CONTR_ID
13
MEDICARE_A
14
MEDICARE_B
15
TPL_IND
Table Name:
AHCCCS_ELIGIBILITY
1
AHCCCS_ID
2
START_DT
3
END_DT
4
CLIENT_ID
5
MHS_CAT
6
CAPITATION_CODE
7
CONTRACT_TYPE
8
CHANGE_CONTROL_DATE
9
CHANGE_CONTROL_USER_ID
10
CIS_ADD_DATE
11
CHANGE_CONTROL_PGM
12
CONTR_ID
13
MEDICARE_A
14
MEDICARE_B
15
TPL_IND
Table Name:
AHCCCS_ENCOUNTER_HIST
1
ICN_NBR
2
LINE_NBR
3
CHANGE_SEQ_NBR
4
CRN_DATE
5
CRN_BATCH
6
CRN_DOC
7
CRN_LINE_NBR
8
CRN_STATUS

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type

Data Length Null?

DATE
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
DATE
VARCHAR2
DATE
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2

7
10
1
4
1
7
30
7
8
2
1
1
1

Y
Y
Y
Y
Y
Y
Y
N
Y
N
Y
Y
Y

VARCHAR2
DATE
DATE
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
DATE
VARCHAR2
DATE
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2

9
7
7
10
1
4
1
7
30
7
8
2
1
1
1

N
N
Y
Y
Y
Y
Y
Y
Y
N
Y
N
Y
Y
Y

VARCHAR2
NUMBER
NUMBER
DATE
NUMBER
NUMBER
NUMBER
VARCHAR2

11
2,0
4,0
7
4,0
3,0
2,0
2

N
N
N
N
N
N
N
N

101

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I

Column_Name

9
CHANGE_CONTROL_DATE
10
CHANGE_CONTROL_PROGRAM
11
AHCCCS_CRN_DATE
Table Name:
AHCCCS_ENCOUNTER_PEND
1
CRN_DATE
2
CRN_BATCH
3
CRN_DOC
4
CRN_LINE_NBR
5
CLAIM_TYPE
6
FORM_TYPE
7
CREATE_DT
8
HEALTH_PLAN
9
AHCCCS_ID
10
SVC_PROV_ID
11
PATIENT_ACCT_NBR
12
CHANGE_CONTROL_DT
13
AHCCCS_CRN_DATE
Table Name:
AHCCCS_ENCOUNTER_PEND_0430
1
CRN_DATE
2
CRN_BATCH
3
CRN_DOC
4
CRN_LINE_NBR
5
CLAIM_TYPE
6
FORM_TYPE
7
CREATE_DT
8
HEALTH_PLAN
9
AHCCCS_ID
10
SVC_PROV_ID
11
PATIENT_ACCT_NBR
12
CHANGE_CONTROL_DT
13
AHCCCS_CRN_DATE
Table Name:
AHCCCS_ENCOUNTER_PEND_DTL
1
CRN_DATE
2
CRN_BATCH
3
CRN_DOC
4
CRN_LINE_NBR
5
INVOICE_NBR
6
REC_TYPE

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type
DATE
VARCHAR2
DATE

Data Length Null?
7
8
7

N
N
N

DATE
NUMBER
NUMBER
NUMBER
CHAR
CHAR
DATE
NUMBER
CHAR
CHAR
CHAR
DATE
DATE

7
4,0
3,0
2,0
1
1
7
6,0
9
6
20
7
7

N
N
N
N
Y
Y
Y
Y
Y
Y
Y
Y
N

DATE
NUMBER
NUMBER
NUMBER
CHAR
CHAR
DATE
NUMBER
CHAR
CHAR
CHAR
DATE
DATE

7
4,0
3,0
2,0
1
1
7
6,0
9
6
20
7
7

N
N
N
N
Y
Y
Y
Y
Y
Y
Y
Y
N

DATE
NUMBER
NUMBER
NUMBER
NUMBER
VARCHAR2

7
4,0
3,0
2,0
6,0
2

N
N
N
N
N
N

102

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I

Column_Name

7
INTERNAL_FLD_NBR
8
OLD_VALUE
9
NEW_VALUE
10
ACTION_CD
11
CCL_LOC
12
FORM_FLD_NM
13
AHCCCS_CRN_DATE
14
CONTR_ID
15
FORM_TYPE
Table Name:
AHCCCS_ENCOUNTER_PEND_ERR
1
CRN_DATE
2
CRN_BATCH
3
CRN_DOC
4
CRN_LINE_NBR
5
REC_TYPE
6
ERR_CD_01
7
ERR_CD_02
8
ERR_CD_03
9
ERR_CD_04
10
ERR_CD_05
11
ERR_CD_06
12
ERR_CD_07
13
ERR_CD_08
14
ERR_CD_09
15
ERR_CD_10
16
ERR_CD_11
17
ERR_CD_12
18
ERR_CD_13
19
ERR_CD_14
20
ERR_CD_15
21
AHCCCS_CRN_DATE
Table Name:
AHCCCS_ENCOUNTER_PEND_ERR_0531
1
CRN_DATE
2
CRN_BATCH
3
CRN_DOC
4
CRN_LINE_NBR
5
REC_TYPE
6
ERR_CD_01

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type

Data Length Null?

VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
DATE
VARCHAR2
VARCHAR2

3
17
17
1
2
15
7
2
1

Y
Y
Y
Y
Y
Y
N
Y
Y

DATE
NUMBER
NUMBER
NUMBER
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
DATE

7
4,0
3,0
2,0
2
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
7

N
N
N
N
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N

DATE
NUMBER
NUMBER
NUMBER
CHAR
CHAR

7
4,0
3,0
2,0
2
4

N
N
N
N
N
Y

103

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I

Column_Name

7
ERR_CD_02
8
ERR_CD_03
9
ERR_CD_04
10
ERR_CD_05
11
ERR_CD_06
12
ERR_CD_07
13
ERR_CD_08
14
ERR_CD_09
15
ERR_CD_10
16
ERR_CD_11
17
ERR_CD_12
18
ERR_CD_13
19
ERR_CD_14
20
ERR_CD_15
21
AHCCCS_CRN_DATE
Table Name:
AHCCCS_ENROLLMENT_HISTORY
1
AHCCCS_ID
2
CLIENT_ID
3
CONTR_ID
4
NAME_LAST
5
NAME_FIRST
6
NAME_MI
7
MHS_CAT
8
ACTION
9
START_DT
10
END_DT
11
REASON_CD
12
INTAKE_DATE
13
PROCESS_DT
Table Name:
AHCCCS_ERROR_TEXT
1
ERROR_NBR
2
ERROR_MESSAGE
3
ERROR_INDICATOR
Table Name:
AHCCCS_MATCH_PERCENTAGE
1
CATEGORY_CODE
2
TRIBAL_CODE
3
CONTRACT_TYPE
4
START_DT

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
DATE

Data Length Null?
4
4
4
4
4
4
4
4
4
4
4
4
4
4
7

Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N

VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
DATE
DATE
VARCHAR2
DATE
DATE

9
10
2
15
10
1
1
2
7
7
2
7
7

N
N
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

VARCHAR2
VARCHAR2
VARCHAR2

4
76
1

N
N
Y

VARCHAR2
VARCHAR2
VARCHAR2
DATE

2
2
1
7

N
N
N
N

104

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I

Column_Name

5
END_DT
6
MONTHLY_CAPITATION_AMOUNT
7
AHCCCS_PERCENTAGE
8
ADHS_PERCENTAGE
9
ADHS_RESERVE_PERCENTAGE
Table Name:
AHCCCS_PLAN_REF
1
HEALTH_PLAN_ID
2
HEALTH_PLAN_NAME
Table Name:
AHCCCS_PROV_PROFILE
1
AHCCCS_PROV_TYPE
2
PROVIDER_COS
3
SER_CODE_FROM
4
SER_CODE_TO
5
COS_MAN_OPT
6
SER_TYPE
7
CHANGE_CONTROL_DATE
8
CHANGE_CONTROL_USER_ID
9
EFF_BEGIN_DATE
10
EFF_END_DATE
Table Name:
AHCCCS_PROV_TRANS
1
DHS_PROVIDER_ID
2
AHCCCS_PROVIDER_TYPE
3
AHCCCS_NAME
4
AHCCCS_LICENSE
5
AHCCCS_PM_SEND_FLAG
6
CHANGE_CONTROL_DATE
7
CHANGE_CONTROL_USER_ID
Table Name:
AHCCCS_PROVIDER_COS
1
AHCCCS_ID
2
PROVIDER_ID
3
PROVIDER_COS
4
START_DT
5
END_DT
6
CHANGE_CONTROL_DATE
7
CHANGE_CONTROL_USER_ID
8
AHCCCS_MATCH_FLAG
Table Name:
AHCCCS_PROVIDER_ENROLL
1
AHCCCS_ID

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type

Data Length Null?

DATE
NUMBER
NUMBER
NUMBER
NUMBER

7
9,2
6,4
6,4
6,4

N
Y
Y
Y
Y

VARCHAR2
VARCHAR2

6
30

N
Y

VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
DATE
VARCHAR2
DATE
DATE

2
2
11
11
1
1
7
30
7
7

N
N
N
N
Y
Y
Y
Y
Y
Y

VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
DATE
VARCHAR2

9
2
50
10
1
7
30

N
Y
Y
Y
Y
Y
Y

VARCHAR2
VARCHAR2
VARCHAR2
DATE
DATE
DATE
VARCHAR2
VARCHAR2

9
9
2
7
7
7
30
1

N
N
N
N
Y
Y
Y
N

VARCHAR2

9

N

105

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I

Column_Name

2
PROVIDER_ID
3
START_DT
4
END_DT
5
AHCCCS_PROV_TYPE
6
CHANGE_CONTROL_DATE
7
CHANGE_CONTROL_USER_ID
8
AHCCCS_MATCH_FLAG
9
AHCCCS_ENROLL_STAT
Table Name:
AHCCCS_ROSTER_HISTORY
1
CLIENT_ID
2
AHCCCS_ID
3
PROCESS_DATE
4
PROCESS_SEQUENCE
5
ACTION_TYPE
6
ACTION_CODE
7
CONTR_ID
8
MHC
9
CAPITATION_RATE_CODE
10
CONTRACT_TYPE
11
ENROLLMENT_FROM_DATE
12
PAYMENT_TO_DATE
13
PRIMARY_AHCCCS_ID
14
ACUTE_HEALTH_PLAN_ID
15
PAYMENT_FROM_DATE
16
VOUCHER_NUMBER
17
CAPITATION_RATE_AMOUNT
18
NUMBER_OF_DAYS
19
CIS_ADD_DATE
Table Name:
AHCCCS_TPL
1
AHCCCS_ID
2
SEQ_NBR
3
PROCESS_DATE
4
LAST_NAME
5
FIRST_NAME
6
SEX
7
DOB
8
POLICY_NBR
9
COVERAGE_TYPE

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type

Data Length Null?

VARCHAR2
DATE
DATE
VARCHAR2
DATE
VARCHAR2
VARCHAR2
VARCHAR2

9
7
7
2
7
30
1
1

N
N
Y
Y
Y
Y
N
N

VARCHAR2
VARCHAR2
DATE
NUMBER
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
DATE
DATE
VARCHAR2
VARCHAR2
DATE
VARCHAR2
NUMBER
NUMBER
DATE

10
9
7
2,0
1
2
2
1
4
1
7
7
9
6
7
9
7,2
3,0
7

N
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

VARCHAR2
VARCHAR2
DATE
VARCHAR2
VARCHAR2
VARCHAR2
DATE
VARCHAR2
VARCHAR2

9
2
7
20
10
1
7
20
1

N
Y
Y
Y
Y
Y
Y
Y
Y

106

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I

Column_Name

10
START_DATE
11
END_DATE
12
CARRIER_NAME
13
CARRIER_PHONE
14
CARRIER_ADDR1
15
CARRIER_ADDR2
16
CARRIER_CITY
17
CARRIER_STATE
18
CARRIER_ZIP
19
INS_LAST_NM
20
INS_FIRST_NM
21
INS_MI
22
RELATIONSHIP
23
INS_EMPLOYER
24
INS_GROUP_NBR
25
ADD_DATE
26
CHANGE_CONTROL_DATE
27
VERIFY_DATE
28
HEALTH_PLAN_ID
Table Name:
AHCCCS_TPL_UPD
1
AHCCCS_ID
2
SEQ_NBR
3
PROCESS_DATE
4
LAST_NAME
5
FIRST_NAME
6
SEX
7
DOB
8
POLICY_NBR
9
COVERAGE_TYPE
10
START_DATE
11
END_DATE
12
CARRIER_NAME
13
CARRIER_PHONE
14
CARRIER_ADDR1
15
CARRIER_ADDR2
16
CARRIER_CITY
17
CARRIER_STATE
18
CARRIER_ZIP

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type

Data Length Null?

DATE
DATE
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
DATE
DATE
DATE
VARCHAR2

7
7
30
10
23
23
18
2
9
20
10
1
1
30
20
7
7
7
6

N
N
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

VARCHAR2
VARCHAR2
DATE
VARCHAR2
VARCHAR2
VARCHAR2
DATE
VARCHAR2
VARCHAR2
DATE
DATE
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2

9
2
7
20
10
1
7
20
1
7
7
30
10
23
23
18
2
9

Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

107

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I

Column_Name

19
INS_LAST_NM
20
INS_FIRST_NM
21
INS_MI
22
RELATIONSHIP
23
INS_EMPLOYER
24
INS_GROUP_NBR
25
ADD_DATE
26
CHANGE_CONTROL_DATE
27
VERIFY_DATE
28
HEALTH_PLAN_ID
Table Name:
ALL_VOIDS
1
CONTR_ID
2
PROVIDER
3
ICN_NBR
4
LINE_NBR
5
CLIENT_ID
6
F_NM
7
M_NM
8
L_NM
9
START_DT
10
END_DT
11
PROCEDURE_CODE
Table Name:
APPL_TABLE_XREF
1
APPLICATION_ID
2
TNAME
3
ACCESS_TYPE
Table Name:
APPLICATION
1
APPLICATION_ID
2
APPLICATION_DESCRIPTION
Table Name:
ASSESS_A_DELETE
1
CONTR_ID
2
CLIENT_ID
3
ASSESS_DT
4
CIS_ADD_DATE
5
ORIG_CIS_PROCESS_DATE
6
CHANGE_CONTROL_DATE
7
CHANGE_CONTROL_PGM
8
CHANGE_CONTROL_USER_ID

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type

Data Length Null?

VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
DATE
DATE
DATE
VARCHAR2

20
10
1
1
30
20
7
7
7
6

Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

VARCHAR2
VARCHAR2
VARCHAR2
NUMBER
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
DATE
DATE
VARCHAR2

2
7
11
,
10
10
1
15
7
7
5

Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

VARCHAR2
VARCHAR2
VARCHAR2

7
30
1

N
N
N

VARCHAR2
VARCHAR2

7
65

N
N

VARCHAR2
VARCHAR2
DATE
DATE
DATE
DATE
VARCHAR2
VARCHAR2

2
10
7
7
7
7
8
8

N
N
N
N
N
N
Y
Y

108

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I

Column_Name

Table Name:
ASSESS_B_DELETE
1
CONTR_ID
2
CLIENT_ID
3
ASSESS_DT
4
CIS_ADD_DATE
5
ORIG_CIS_PROCESS_DATE
6
CHANGE_CONTROL_DATE
7
CHANGE_CONTROL_PGM
8
CHANGE_CONTROL_USER_ID
Table Name:
ASSESSMENT_A
1
CLIENT_ID
2
CONTR_ID
3
ASSESS_DT
4
INTAKE_DATE
5
INTERVAL
6
ASSESSB_DT
7
RESIDENCE
8
FAMILY_SETTING
9
HOUSEHOLD
10
EMPLOYMENT_STAT
11
ARREST_PY_PROTECT
12
ARREST_SA_PROTECT
13
ARREST_PY_ALCOHOL
14
ARREST_SA_ALCOHOL
15
ARREST_PY_DRUG
16
ARREST_SA_DRUG
17
ARREST_PY_VIOLENT
18
ARREST_SA_VIOLENT
19
ARREST_PY_FELONY
20
ARREST_SA_FELONY
21
ARREST_PY_MISDEM
22
ARREST_SA_MISDEM
23
PSYCHO_MEDS
24
CLIENT_ELIG_SSI
25
CLIENT_ELIG_SSDI
26
SUBSTANCE_1
27
FREQ_SUB_USE_1
28
ROUTE_1

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type

Data Length Null?

VARCHAR2
VARCHAR2
DATE
DATE
DATE
DATE
VARCHAR2
VARCHAR2

2
10
7
7
7
7
8
8

N
N
N
N
N
N
Y
Y

VARCHAR2
VARCHAR2
DATE
DATE
NUMBER
DATE
NUMBER
NUMBER
NUMBER
VARCHAR2
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
VARCHAR2
NUMBER
NUMBER

10
2
7
7
1,0
7
1,0
1,0
1,0
2
2,0
2,0
2,0
2,0
2,0
2,0
2,0
2,0
2,0
2,0
2,0
2,0
1,0
1,0
1,0
4
1,0
1,0

N
N
N
N
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

109

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I

Column_Name

29
AGE_FIRST_USE_1
30
SUBSTANCE_2
31
FREQ_SUB_USE_2
32
ROUTE_2
33
AGE_FIRST_USE_2
34
SUBSTANCE_3
35
FREQ_SUB_USE_3
36
ROUTE_3
37
AGE_FIRST_USE_3
38
ASSESSA_PROB_1
39
ASSESSA_PROB_2
40
ASSESSA_PROB_3
41
ASSESSA_PROB_4
42
ASSESSA_PROB_5
43
AXIS_I_1
44
AXIS_I_2
45
AXIS_II_1
46
AXIS_II_2
47
AXIS_III_1
48
AXIS_III_2
49
AXIS_IV
50
AXIS_V_GAF
51
SMI_FLAG
52
SED_FLAG
53
IV_DRUG_FLAG
54
PREGNANT_FLAG
55
WOMAN_DEP_FLAG
56
METHADONE_TREATMENT
57
CHANGE_CONTROL_DATE
58
CHANGE_CONTROL_USER_ID
59
CIS_ADD_DATE
60
CHANGE_CONTROL_PGM
61
CONTRACTOR_RESEARCH
62
DIVISION_RESEARCH
Table Name:
ASSESSMENT_B
1
CLIENT_ID
2
CONTR_ID
3
INTAKE_DATE

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type

Data Length Null?

NUMBER
VARCHAR2
NUMBER
NUMBER
NUMBER
VARCHAR2
NUMBER
NUMBER
NUMBER
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
NUMBER
NUMBER
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
DATE
VARCHAR2
DATE
VARCHAR2
VARCHAR2
VARCHAR2

2,0
4
1,0
1,0
2,0
4
1,0
1,0
2,0
2
2
2
2
2
6
6
6
6
6
6
1,0
2,0
1
1
1
1
1
1
7
30
7
8
10
10

Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

VARCHAR2
VARCHAR2
DATE

12
4
7

N
N
N

110

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42

ASSESS_DT
SUICIDAL
ASSAULTIVE
WALKAWAY_POTENTIAL
GRAVELY_DISABLED
DANGER_TO_SELF
DANGER_TO_OTHERS
EVER_VICTIM_PHYS_ABUSE
EVER_VICTIM_SEX_ABUSE
EVER_SUBST_ABUSE_IN_FAM
ANXIOUS_NERVOUS
FEARS_PHOBIAS
ANGER_HOSTILITY
GUILTY_FEELINGS
SLEEP_PROBLEMS
DEPRESSION
WORTHLESSNESS_SELF_EST
LONELINESS
BOREDOM_NO_PURPOSE
FEELINGS_EASILLY_HURT
MANIC_RESTLESS
MOOD_SWINGS
FATIGUE_LOW_ENERGY
POOR_MEMORY
LOW_INTELLIGENCE
CONFUSION
IMPAIRED_JUDGEMENT
POOR_ATTENTION_SPAN
LEARNING_DISABILITY
BIZARRE_THOUGHTS
REPEATED_THOUGHTS
HALLUCINATIONS
DELUSIONS
PARANOID
ACUTE_ILLNESS
CHRONIC_ILLNESS
NUTRITION_WEIGHT
EATING_DISORDER
CENT_NEURO_DISORDER

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

DATE
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER

7
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
4,0
10,0
10,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0

N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

111

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I
43
44
45
46
47
48
49
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80

Column_Name
PERMANENT_DISABILITY
INJ_BY_ABUSE_OR_ASSAULT
INTERFERES_W_RELATIONSHIPS
INTERFERES_W_ROLE_PERF
UNABLE_TO_CONTROL_USE
EXPER_PHYS_EFFECTS
INTERFERES_W_DLY_FUNCTN
DEPENDENCY_ADDICTION
PROB_W_PRIMARY_PARTNER
PROB_W_OTHER_RELATIVES
PARENTING_PROBLEMS
NEGLECT_OR_ABUSE_OF_FAM
FAMILY_INSTABILITY
FAMILY_VIOLENCE
PROBLEMS_WITH_FRIENDS
LACKS_SOCIAL_SKILLS
ESTABLISH_RELATIONSHIPS
MAINTAIN_RELATIONSHIPS
ABSENTEEISM
PERFORMANCE_PROBLEMS
BEHAVIOR_PROBLEMS
TERMINATION_EXPULSION
MANAGE_PERSNL_ENVIRON
DISREGARDS_RULES
DISHONEST
RESISTIVE
BELLIGERENT
USES_OR_CONS_OTHERS
OFFENSES_AGAINST_PERSNS
OFFENSES_AGAINST_PROPRTY
HAS_CURR_LEGAL_PROBLEMS
PROVIDE_OWN_FOOD
PROVIDE_OWN_CLOTHING
PROVIDE_OWN_HOUSING
PROVIDE_OWN_TRANSPORTN
READ_AND_WRITE
MANAGE_MONEY
EARN_MONEY

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER

Data Length Null?
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0
1,0

Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

112

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
81
DO_HOUSEHOLD_CHORES
82
FOLLOW_A_SCHEDULE
83
PREPARE_ADEQUATE_MEALS
84
MAINTAIN_PRSNL_HYGENE
85
DRESS_APPROPRIATELY
86
MAKE_REASONABLE_DECSIONS
87
OBTAIN_HEALTH_CARE
88
FEELNG_AFFECT_MOOD_FUNC
89
THINK_MNTL_PROC_FUNCT
90
MEDICAL_PHYSICAL_FUNCT
91
SUBSTANCE_ABUSE_FUNCT
92
FAM_LIVNG_SITUATN_FUNCT
93
INTERPRSNL_RLNS_FUNCT
94
ROLE_PERFMNCE_FUNCT
95
SOCIO_LEGAL_FUNCTIONING
96
SELFCARE_BAS_NEEDS_FUNC
97
CHANGE_CONTROL_DATE
98
CHANGE_CONTROL_USER_ID
99
CIS_ADD_DATE
100
CHANGE_CONTROL_PGM
101
INTERVAL
102
CONTRACTOR_RESEARCH
103
DIVISION_RESEARCH
Table Name:
BALANCE_ACTIVITY_DETAIL
1
TRANSACTION_NBR
2
PRIOR_AUTH_NBR
3
CLIENT_ID
4
PROCEDURE_CODE
5
EFFECTIVE_DT
6
CANCEL_DT
7
SVC_TYPE
8
EDS_UPDATE_DT
9
PROGRAM_CODE
10
SEQUENCE_NBR
11
START_DT
12
END_DT
13
ICN_NBR
14
LINE_NBR
15
CHANGE_CONTROL_DATE

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
DATE
VARCHAR2
DATE
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2

1,0
1,0
1,0
1,0
10,0
1,0
1,0
2,0
2,0
2,0
2,0
2,0
2,0
2,0
2,0
2,0
7
30
7
8
1
10
10

Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

NUMBER
VARCHAR2
VARCHAR2
VARCHAR2
DATE
DATE
VARCHAR2
DATE
VARCHAR2
NUMBER
DATE
DATE
VARCHAR2
NUMBER
DATE

9,0
6
10
5
7
7
1
7
1
3,0
7
7
11
2,0
7

N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

113

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I

Column_Name

16
CONTR_ID
17
ALLOCATION_REDUCTION
18
ACTIVITY_TYPE
19
ACTIVITY_DT
20
TRANSACTION_AMOUNT
21
AHCCCS_ID
22
AHCCCS_START_DT
23
PROGRAM_STAMP
Table Name:
BATCH_LOG
1
CONTR_ID
2
SUB_CONTR_ID
3
FACILITY_ID
4
BATCH_DATE
5
BATCH_SEQ_NBR
6
BATCH_FORM_CNT_001
7
BATCH_FORM_CNT_002
8
BATCH_FORM_CNT_003
9
BATCH_FORM_CNT_004
10
BATCH_FORM_CNT_005B
11
BATCH_FORM_CNT_005
12
BATCH_FORM_CNT_006B
13
BATCH_FORM_CNT_006
14
BATCH_FORM_CNT_007
15
BATCH_FORM_CNT_008
16
ACTUAL_FORM_CNT_001
17
ACTUAL_FORM_CNT_002
18
ACTUAL_FORM_CNT_003
19
ACTUAL_FORM_CNT_004
20
ACTUAL_FORM_CNT_005B
21
ACTUAL_FORM_CNT_005
22
ACTUAL_FORM_CNT_006B
23
ACTUAL_FORM_CNT_006
24
ACTUAL_FORM_CNT_007
25
ACTUAL_FORM_CNT_008
26
REJECT_FORM_CNT_001
27
REJECT_FORM_CNT_002
28
REJECT_FORM_CNT_003
29
REJECT_FORM_CNT_004

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type

Data Length Null?

VARCHAR2
NUMBER
VARCHAR2
DATE
NUMBER
VARCHAR2
DATE
VARCHAR2

2
9,2
3
7
9,2
9
7
4

Y
Y
Y
Y
Y
Y
Y
Y

VARCHAR2
VARCHAR2
VARCHAR2
DATE
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER

2
4
3
7
4,0
5,0
5,0
5,0
5,0
5,0
5,0
5,0
5,0
5,0
5,0
5,0
5,0
5,0
5,0
5,0
5,0
5,0
5,0
5,0
5,0
5,0
5,0
5,0
5,0

N
N
N
N
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

114

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I

Column_Name

30
REJECT_FORM_CNT_005B
31
REJECT_FORM_CNT_005
32
REJECT_FORM_CNT_006B
33
REJECT_FORM_CNT_006
34
REJECT_FORM_CNT_007
35
REJECT_FORM_CNT_008
36
ERROR_NBR
37
REPORT_RUN_DATE
38
CHANGE_CONTROL_DATE
39
CHANGE_CONTROL_USER_ID
Table Name:
BUDGET_DETAIL_COMPONENT
1
PROGRAM_CODE
2
RESTRICTION_CODE
3
DIVISION_CODE
4
FUNDING_SOURCE
5
ACTIVITY_CODE
6
FUND_START_DT
7
FUND_END_DT
8
AMOUNT
Table Name:
BUSINESS_MONTH
1
BUSINESS_MONTH
2
MONTH_BEG_DATE
3
MONTH_END_DATE
4
PROCESS_DATE
Table Name:
CAPITATION_DAILY_RATE
1
CONTR_ID
2
PROGRAM_CODE
3
AHCCCS_IND
4
RATE_BEG_DATE
5
RATE_END_DATE
6
MONTH_BEG_DATE
7
MONTH_END_DATE
8
ADM_CAP_AMT
9
CASE_MGT_CAP_AMT
10
CASE_SERVICE_CAP_AMT
11
NON_CASE_SERVICE_CAP_AMT

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type

Data Length Null?

NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
DATE
DATE
VARCHAR2

5,0
5,0
5,0
5,0
5,0
5,0
3,0
7
7
30

Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
DATE
DATE
NUMBER

1
2
2
2
6
7
7
9,2

N
N
N
N
N
Y
Y
Y

NUMBER
DATE
DATE
DATE

6,0
7
7
7

N
N
N
N

VARCHAR2
VARCHAR2
VARCHAR2
DATE
DATE
DATE
DATE
NUMBER
NUMBER
NUMBER
NUMBER

2
1
1
7
7
7
7
8,4
8,4
8,4
8,4

N
N
N
N
N
N
N
Y
Y
Y
Y

115

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual

Column_I

Column_Name

Table Name:
CAPITATION_ESTIMATE
1
CONTR_ID
2
FY
3
TOTAL_POPULATION
4
NATIVE_AMERICAN
5
NON_NATIVE_AMERICAN
6
CHANGE_CONTROL_PGM
7
CHANGE_CONTROL_DATE
8
CHANGE_CONTROL_USER_ID
Table Name:
CAPITATION_RATE
1
CONTR_ID
2
PROGRAM_CODE
3
AHCCCS_IND
4
RATE_BEG_DATE
5
RATE_END_DATE
6
ADM_CAP_AMT
7
CASE_MGT_CAP_AMT
8
CASE_SERVICE_CAP_AMT
9
NON_CASE_SERVICE_CAP_AMT
10
CHANGE_CONTROL_DATE
11
CHANGE_CONTROL_USER_ID
Table Name:
CAPZIP_REPORT
1
RP_ZIP
2
ACT_TYP
Table Name:
CASE_MGR
1
CONTR_ID
2
CASE_MGR_ID
3
REGISTER_DT
4
OBSOLETE_DATE
5
F_NM
6
M_NM
7
L_NM
8
CASE_MGR_PHONE
9
YEAR_OF_BIRTH
10
SEX
11
RACE
12
EDUC

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type

Data Length Null?

VARCHAR2
VARCHAR2
NUMBER
NUMBER
NUMBER
VARCHAR2
DATE
VARCHAR2

2
9
9,0
9,0
9,0
8
7
30

Y
Y
Y
Y
Y
Y
Y
Y

VARCHAR2
VARCHAR2
VARCHAR2
DATE
DATE
NUMBER
NUMBER
NUMBER
NUMBER
DATE
VARCHAR2

2
1
1
7
7
7,2
7,2
7,2
7,2
7
30

N
N
N
N
N
Y
Y
Y
Y
Y
Y

VARCHAR2
VARCHAR2

9
1

Y
Y

VARCHAR2
NUMBER
DATE
DATE
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
NUMBER
VARCHAR2
NUMBER
NUMBER

2
5,0
7
7
15
15
15
7
2,0
1
1,0
2,0

N
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

116

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I

Column_Name

13
LANGUAGE_SPOKEN_1
14
LANGUAGE_SPOKEN_2
15
LANGUAGE_SPOKEN_3
16
LANGUAGE_SPOKEN_4
17
GOVT_LICENSE_AZ
18
GOVT_LICENSE_OTHER_STATE
19
GOVT_LICENSE_OTHER_COUNTRY
20
BOARD_CERT_AZ
21
BOARD_CERT_OTHER_STATE
22
BOARD_CERT_OTHER_COUNTRY
23
DIRECT_ADJUNCTV_CLIENT_CARE
24
CONSULT_EDUCATION_PREVENTN
25
ADMIN_MANAGEMENT
26
OTHER_JOB_FUNCTION
27
TRAINING
28
CHANGE_CONTROL_DATE
29
CHANGE_CONTROL_USER_ID
30
LOCATION
31
TEAM
32
CIS_ADD_DATE
33
CHANGE_CONTROL_PGM
Table Name:
CDS_SERVICE_CODE
1
CDS_SERVICE_CODE
2
DESCR
Table Name:
CHECK_POINT
1
PROGRAM_ID
2
LAST_CHECKPOINT
3
CHANGE_CONTROL_DATE
Table Name:
CIS_PROVIDER_HISTORY
1
CONTR_ID
2
SUB_CONTR_ID
3
FACILITY_ID
4
START_DT
5
END_DT
6
ELIGIBLE_CD
7
STATUS_CD
8
REASON_CD
9
PROV_TYPE

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type

Data Length Null?

NUMBER
NUMBER
NUMBER
NUMBER
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
DATE
VARCHAR2
VARCHAR2
VARCHAR2
DATE
VARCHAR2

1,0
1,0
1,0
1,0
1
1
1
1
1
1
3,0
3,0
3,0
3,0
2,0
7
30
2
1
7
8

Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

VARCHAR2
VARCHAR2

2
40

N
N

VARCHAR2
VARCHAR2
DATE

6
240
7

N
Y
Y

VARCHAR2
VARCHAR2
VARCHAR2
DATE
DATE
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2

2
4
3
7
7
2
1
2
2

Y
Y
Y
Y
Y
Y
Y
Y
Y

117

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I

Column_Name

10
CHANGE_CONTROL_DATE
11
CHANGE_CONTROL_USER_ID
12
CHANGE_CONTROL_PGM
Table Name:
CIS_VERSION
1
VERSION_NBR
2
VERSION_DATE
3
IP_ADDRESS
4
USERID
5
PASSWORD
6
SOURCEFILE
7
TARGETFILE
Table Name:
CLIENT_CLOSURE
1
CLIENT_ID
2
CONTR_ID
3
INTAKE_DT
4
EVENT_DATE
5
EVENT_TYPE
6
EVENT_REASON
7
PROVIDER_TYPE
8
RBHA_CLIENT_ID
9
ACTION_CODE
Table Name:
CLIENT_INCARC_HIST
1
INCARC_SEQ_NBR
2
CLIENT_ID
3
CONTR_ID
4
INTAKE_DATE
5
INCARC_START_DT
6
CHANGE_CONTROL_USER_ID
7
CHANGE_CONTROL_DATE
8
INCARC_VOID
9
INCARC_END_DT
10
AHCCCS_ID
Table Name:
CLIENT_INTAKE
1
CONTR_ID
2
CLIENT_ID
3
INTAKE_DATE
4
AHCCCS_ID
5
SSNO

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type

Data Length Null?

DATE
VARCHAR2
VARCHAR2

7
30
8

Y
Y
Y

VARCHAR2
DATE
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2

5
7
16
10
10
40
40

Y
Y
Y
Y
Y
Y
Y

VARCHAR2
VARCHAR2
DATE
DATE
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2

10
2
7
7
1
2
2
10
1

N
N
N
N
Y
Y
Y
Y
Y

NUMBER
VARCHAR2
VARCHAR2
DATE
DATE
VARCHAR2
DATE
VARCHAR2
DATE
VARCHAR2

6,0
10
2
7
7
30
7
1
7
9

N
N
N
N
N
N
N
Y
Y
Y

VARCHAR2
VARCHAR2
DATE
VARCHAR2
VARCHAR2

2
10
7
9
10

N
Y
N
Y
Y

118

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43

Column_Name
F_NM
M_NM
L_NM
INTAKE_TYPE
DOB
SEX
RACE
HEALTH_PLAN
ADDRESS_LINE_1
ADDRESS_LINE_2
CITY
STATE
ZIP_CODE
VETERAN
COUNTY_RESIDENCE
CENSUS_TRACT
CENSUS_PLACE
MED_INSURANCE_1
MED_INSURANCE_2
MED_INSURANCE_3
INC_SOURCE_1
INC_SOURCE_2
INC_SOURCE_3
FAMILY_SIZE
INCOME
MARITAL_STAT
DAYS_WAITING_TREAT
EDUC
PAYMENT_SOURCE
LEGAL_STAT
OTHER_AGENCY_1
OTHER_AGENCY_2
OTHER_AGENCY_3
SMI_FLAG
SED_FLAG
IV_DRUG_FLAG
PREGNANT_FLAG
WOMAN_DEP_FLAG

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
DATE
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
NUMBER
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2

Data Length Null?
10
1
15
1
7
1
2
6
25
25
20
2
9
1
2
6,2
4
2
2
2
2
2
2
2
2
1
3
2
2
1
1
1
1
1
1
1
1
1

Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

119

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I

Column_Name

44
DNHS_HANDICAP
45
REFERRAL
46
CASE_MGR_ID
47
CLOSURE_DATE
48
ASSESS_DT
49
ASSESS_SMI_FLAG
50
ASSESS_SED_FLAG
51
ASSESS_IV_DRUG_FLAG
52
ASSESS_PREGNANT_FLAG
53
ASSESS_WOMAN_DEP_FLAG
54
EDS_ADD_DT
55
EDS_UPDATE_ID
56
EDS_UPDATE_DT
57
EDS_FILE_DT
58
PROGRAM_IND
59
INCARC_STATUS
60
CIS_ADD_DATE
61
CHANGE_CONTROL_DATE
62
CHANGE_CONTROL_PGM
63
CHANGE_CONTROL_USER_ID
64
WITHDRAWAL_INDICATOR
65
WITHDRAWAL_DATE
66
RBHA_CLIENT_ID
67
ACTION_CODE
68
NEW_INTAKE_DATE
Table Name:
CLIENTID_CONVERSION
1
CLIENT_ID
2
CLIENT_NUMBER
Table Name:
CLOSURE
1
CLIENT_ID
2
CONTR_ID
3
INTAKE_DT
4
EVENT_DATE
5
EVENT_TYPE
6
EVENT_REASON
7
PROVIDER_TYPE
8
EDS_ADD_DT
9
EDS_UPDATE_ID

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type

Data Length Null?

VARCHAR2
VARCHAR2
VARCHAR2
DATE
DATE
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
DATE
VARCHAR2
DATE
DATE
VARCHAR2
VARCHAR2
DATE
DATE
VARCHAR2
VARCHAR2
VARCHAR2
DATE
VARCHAR2
VARCHAR2
DATE

2
2
5
7
7
1
1
1
1
1
7
8
7
7
1
1
7
7
8
8
1
7
10
1
7

Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

VARCHAR2
NUMBER

10
,

N
Y

VARCHAR2
VARCHAR2
DATE
DATE
VARCHAR2
VARCHAR2
VARCHAR2
DATE
VARCHAR2

10
2
7
7
1
2
2
7
8

N
N
N
N
Y
Y
Y
Y
Y

120

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I

Column_Name

10
EDS_UPDATE_DT
11
EDS_FILE_DT
12
CIS_ADD_DATE
13
CHANGE_CONTROL_DATE
14
CHANGE_CONTROL_PGM
15
CHANGE_CONTROL_USER_ID
16
RBHA_CLIENT_ID
Table Name:
CLOSURE_INTAKE_DT_CHG
1
CONTR_ID
2
CLIENT_ID
3
INTAKE_DT
4
PRIOR_INTAKE_DATE
5
CHANGE_CONTROL_DATE
6
CHANGE_CONTROL_PGM
7
CHANGE_CONTROL_USER_ID
Table Name:
CODE_TABLE
1
TNAME
2
REMARKS
3
CNAME1
4
COLTYPE1
5
WIDTH1
6
CNAME2
7
COLTYPE2
8
WIDTH2
9
CNAME3
10
COLTYPE3
11
WIDTH3
Table Name:
CODE_VALUE
1
TNAME
2
TCODE
3
START_DATE
4
OBSOLETE_DATE
5
DESCR
6
DICTIONARY_ID
Table Name:
CONTRACT_PROGRAM
1
CONTR_ID
2
PROGRAM_CODE
3
CONTRACT_NBR

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type

Data Length Null?

DATE
DATE
DATE
DATE
VARCHAR2
VARCHAR2
VARCHAR2

7
7
7
7
8
8
10

Y
Y
Y
Y
Y
Y
Y

VARCHAR2
VARCHAR2
DATE
DATE
DATE
VARCHAR2
VARCHAR2

2
10
7
7
7
8
8

N
N
N
N
N
N
Y

VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
NUMBER
VARCHAR2
VARCHAR2
NUMBER
VARCHAR2
VARCHAR2
NUMBER

30
80
30
1
2,0
30
1
2,0
30
1
2,0

N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

VARCHAR2
VARCHAR2
DATE
DATE
VARCHAR2
VARCHAR2

30
6
7
7
30
7

N
N
N
Y
Y
Y

VARCHAR2
VARCHAR2
NUMBER

2
1
10,0

N
N
Y

121

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I

Column_Name

4
CONTRACT_START_DT
5
CONTRACT_END_DT
6
MAXIMUM_DOLLAR_AMOUNT
Table Name:
CONTRACTOR
1
CONTR_ID
2
CONTR_SHORT_NAME
3
CONTR_LONG_NAME
4
ADDRESS_1
5
ADDRESS_2
6
CITY
7
STATE
8
ZIP_5
9
ZIP_4
10
T19_EFFECTIVE_FROM_DT
11
T19_EFFECTIVE_TO_DT
12
T19_CONTRACT_IND
13
BHS_CONTRACT_IND
14
BHS_EFFECTIVE_FROM_DT
15
BHS_EFFECTIVE_TO_DT
Table Name:
CUR_CIS
1
AHCCCS_ID
2
CONTR_ID
3
START_DT
Table Name:
DIAGNOSIS_CD
1
DIAGNOSIS
2
EFFECTIVE_DT
3
OBSOLETE_DT
4
CATEGORY
5
DESCR
6
ICD_9
7
SEX
8
MINAGE
9
MAXAGE
10
SMI_FLAG
11
SED_FLAG

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type
DATE
DATE
NUMBER

Data Length Null?
7
7
11,2

Y
Y
Y

VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
NUMBER
NUMBER
DATE
DATE
VARCHAR2
VARCHAR2
DATE
DATE

2
10
50
25
25
15
2
5,0
4,0
7
7
1
1
7
7

N
N
N
Y
Y
Y
Y
Y
Y
Y
Y
N
N
Y
Y

VARCHAR2
VARCHAR2
DATE

9
2
7

N
N
Y

VARCHAR2
DATE
DATE
NUMBER
VARCHAR2
VARCHAR2
VARCHAR2
NUMBER
NUMBER
VARCHAR2
VARCHAR2

6
7
7
2,0
90
6
1
2,0
2,0
1
1

N
N
Y
Y
Y
Y
Y
Y
Y
Y
Y

122

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I
Table Name:
EDS_FILE_LOG
1
EDS_FILE_NAME
2
RECORD_COUNT
3
TRANSFER_DT
4
PROCESS_DT
5
FLOOR_DT
Table Name:
EDS_INTAKE
1
CONTR_ID
2
CLIENT_ID
3
INTAKE_DATE
4
AHCCCS_ID
5
SSNO
6
F_NM
7
M_NM
8
L_NM
9
INTAKE_TYPE
10
DOB
11
SEX
12
RACE
13
HEALTH_PLAN
14
ADDRESS_LINE_1
15
ADDRESS_LINE_2
16
CITY
17
STATE
18
ZIP_CODE
19
VETERAN
20
COUNTY_RESIDENCE
21
CENSUS_TRACT
22
CENSUS_PLACE
23
MED_INSURANCE_1
24
MED_INSURANCE_2
25
MED_INSURANCE_3
26
INC_SOURCE_1
27
INC_SOURCE_2
28
INC_SOURCE_3
29
FAMILY_SIZE
30
INCOME
31
MARITAL_STAT

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Column_Name

Data Type

Data Length Null?

VARCHAR2
NUMBER
DATE
DATE
DATE

8
8,0
7
7
7

N
N
N
Y
Y

VARCHAR2
VARCHAR2
DATE
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
DATE
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
NUMBER
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2

2
10
7
9
10
10
1
15
1
7
1
2
6
25
25
20
2
9
1
2
6,2
4
2
2
2
2
2
2
2
2
1

N
N
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

123

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I

Column_Name

32
DAYS_WAITING_TREAT
33
EDUC
34
PAYMENT_SOURCE
35
LEGAL_STAT
36
OTHER_AGENCY_1
37
OTHER_AGENCY_2
38
OTHER_AGENCY_3
39
SMI_FLAG
40
SED_FLAG
41
IV_DRUG_FLAG
42
PREGNANT_FLAG
43
WOMAN_DEP_FLAG
44
DNHS_HANDICAP
45
REFERRAL
46
CASE_MGR_ID
47
CLOSURE_DATE
48
ASSESS_DT
49
ASSESS_SMI_FLAG
50
ASSESS_SED_FLAG
51
ASSESS_IV_DRUG_FLAG
52
ASSESS_PREGNANT_FLAG
53
ASSESS_WOMAN_DEP_FLAG
54
EDS_ADD_DT
55
EDS_UPDATE_ID
56
EDS_UPDATE_DT
57
EDS_FILE_DT
58
PROGRAM_IND
59
INCARC_STATUS
60
CIS_ADD_DATE
61
CHANGE_CONTROL_DATE
62
CHANGE_CONTROL_PGM
63
CHANGE_CONTROL_USER_ID
64
WITHDRAWAL_INDICATOR
65
WITHDRAWAL_DATE
66
RBHA_CLIENT_ID
Table Name:
EDS_INTAKE_DELETE
1
CONTR_ID
2
CLIENT_ID

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type

Data Length Null?

VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
DATE
DATE
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
DATE
VARCHAR2
DATE
DATE
VARCHAR2
VARCHAR2
DATE
DATE
VARCHAR2
VARCHAR2
VARCHAR2
DATE
VARCHAR2

3
2
2
1
1
1
1
1
1
1
1
1
2
2
5
7
7
1
1
1
1
1
7
8
7
7
1
1
7
7
8
8
1
7
10

Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

VARCHAR2
VARCHAR2

2
10

N
N

124

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40

Column_Name
INTAKE_DATE
AHCCCS_ID
SSNO
F_NM
M_NM
L_NM
INTAKE_TYPE
DOB
SEX
RACE
HEALTH_PLAN
ADDRESS_LINE_1
ADDRESS_LINE_2
CITY
STATE
ZIP_CODE
VETERAN
COUNTY_RESIDENCE
CENSUS_TRACT
CENSUS_PLACE
MED_INSURANCE_1
MED_INSURANCE_2
MED_INSURANCE_3
INC_SOURCE_1
INC_SOURCE_2
INC_SOURCE_3
FAMILY_SIZE
INCOME
MARITAL_STAT
DAYS_WAITING_TREAT
EDUC
PAYMENT_SOURCE
LEGAL_STAT
OTHER_AGENCY_1
OTHER_AGENCY_2
OTHER_AGENCY_3
SMI_FLAG
SED_FLAG

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type
DATE
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
DATE
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
NUMBER
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2

Data Length Null?
7
9
10
10
1
15
1
7
1
2
6
25
25
20
2
9
1
2
6,2
4
2
2
2
2
2
2
2
2
1
3
2
2
1
1
1
1
1
1

N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

125

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I

Column_Name

41
IV_DRUG_FLAG
42
PREGNANT_FLAG
43
WOMAN_DEP_FLAG
44
DNHS_HANDICAP
45
REFERRAL
46
CASE_MGR_ID
47
CLOSURE_DATE
48
ASSESS_DT
49
ASSESS_SMI_FLAG
50
ASSESS_SED_FLAG
51
ASSESS_IV_DRUG_FLAG
52
ASSESS_PREGNANT_FLAG
53
ASSESS_WOMAN_DEP_FLAG
54
EDS_ADD_DT
55
EDS_UPDATE_ID
56
EDS_UPDATE_DT
57
EDS_FILE_DT
58
PROGRAM_IND
59
INCARC_STATUS
60
CIS_ADD_DATE
61
CHANGE_CONTROL_DATE
62
CHANGE_CONTROL_PGM
63
CHANGE_CONTROL_USER_ID
64
WITHDRAWAL_INDICATOR
65
WITHDRAWAL_DATE
66
RBHA_CLIENT_ID
Table Name:
EDS_INTAKE_DT_CHG
1
CONTR_ID
2
CLIENT_ID
3
INTAKE_DT
4
PRIOR_INTAKE_DATE
5
CHANGE_CONTROL_DATE
6
CHANGE_CONTROL_PGM
7
CHANGE_CONTROL_USER_ID
Table Name:
EDS_LEVEL_3_RATES
1
PROCEDURE_CODE
2
EFFECTIVE_DATE
3
END_DATE

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type

Data Length Null?

VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
DATE
DATE
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
DATE
VARCHAR2
DATE
DATE
VARCHAR2
VARCHAR2
DATE
DATE
VARCHAR2
VARCHAR2
VARCHAR2
DATE
VARCHAR2

1
1
1
2
2
5
7
7
1
1
1
1
1
7
8
7
7
1
1
7
7
8
8
1
7
10

Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

VARCHAR2
VARCHAR2
DATE
DATE
DATE
VARCHAR2
VARCHAR2

2
10
7
7
7
8
8

N
N
N
N
N
N
Y

VARCHAR2
DATE
DATE

5
7
7

N
N
Y

126

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I

Column_Name

4
MAX_CAP_RATE
5
RATE_SEQ
Table Name:
ELIG_ENROLL_TRAN
1
TRAN_TYPE
2
CLIENT_ID
3
CONTR_ID
4
INTAKE_DATE
5
START_DT
6
END_DT
7
CIS_ADD_DATE
8
CHANGE_CONTROL_DATE
9
CHANGE_CONTROL_PGM
10
CHANGE_CONTROL_USER_ID
Table Name:
ELIG_GAP
1
CONTR_ID
2
CLIENT_ID
3
AHCCCS_ID
4
GAP_BEGIN_DT
5
GAP_END_DT
Table Name:
ENC_MULT_INTKE
1
CONTR_ID
2
CLIENT_ID
3
PROCEDURE_CODE
4
START_DT
5
END_DT
6
EDS_ADD_DT
Table Name:
ENCOUNTER
1
ICN_NBR
2
LINE_NBR
3
CHANGE_SEQ_NBR
4
PRIOR_AUTH_NBR
5
CLIENT_ID
6
PROCEDURE_CODE
7
CONTR_ID
8
SUB_CONTR_ID
9
FACILITY_ID
10
START_DT
11
END_DT

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type

Data Length Null?

NUMBER
NUMBER

9,2
4,0

Y
N

VARCHAR2
VARCHAR2
VARCHAR2
DATE
DATE
DATE
DATE
DATE
VARCHAR2
VARCHAR2

1
10
2
7
7
7
7
7
8
8

N
N
N
N
N
Y
N
N
Y
Y

VARCHAR2
VARCHAR2
VARCHAR2
DATE
DATE

2
10
9
7
7

Y
Y
Y
Y
Y

VARCHAR2
VARCHAR2
VARCHAR2
DATE
DATE
DATE

2
10
5
7
7
7

Y
Y
Y
Y
Y
Y

VARCHAR2
NUMBER
NUMBER
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
DATE
DATE

11
2,0
4,0
6
10
5
2
4
3
7
7

N
N
N
Y
Y
Y
Y
Y
Y
Y
Y

127

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49

Column_Name
ADJUSTMENT_FLAG
SVC_TYPE
DIAGNOSIS_CODE
UNIT_OF_SERVICE
ALLOWABLE_CHARGE
PATIENT_STATUS
ATTENDING_PHYSICIAN
ADMISSION_TYPE
ADMISSION_DT
BILL_TYPE
NDC_CODE
ENCOUNTER_PENDING
CRN_NBR
EDS_ADD_DT
EDS_FILE_DT
CHANGE_CONTROL_DATE
AHCCCS_SEND_DT
NET_PAID
DISPENSE_QUANTITY
AHCCCS_LINE_NBR
ADJUSTMENT_ICN
SPECIAL_NET_VALUE
ENCOUNTER_FORM_TYPE
EDS_UPDATE_DT
CIS_ADD_DATE
CHANGE_CONTROL_PGM
CHANGE_CONTROL_USER_ID
ADMISSION_SOURCE
OCCURRENCE_CODE
OCCURRENCE_DATE
OTHER_INS_COV_FLAG
OTHER_INS_PAYMENT
PRIN_PROC_CODE
PRIN_PROC_DATE
OTHER_PROC_CODE
OTHER_PROC_DATE
MED_PROC_CODE_MODIFIER
ENCOUNTER_PROCESS_DT

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type
VARCHAR2
VARCHAR2
VARCHAR2
NUMBER
NUMBER
VARCHAR2
VARCHAR2
VARCHAR2
DATE
VARCHAR2
VARCHAR2
VARCHAR2
NUMBER
DATE
DATE
DATE
DATE
NUMBER
NUMBER
NUMBER
VARCHAR2
NUMBER
VARCHAR2
DATE
DATE
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
DATE
VARCHAR2
NUMBER
VARCHAR2
DATE
VARCHAR2
DATE
VARCHAR2
DATE

Data Length Null?
1
1
6
7,1
7,2
2
9
1
7
3
11
1
14,0
7
7
7
7
7,2
4,0
2,0
11
7,2
1
7
7
8
8
1
2
7
1
8,2
5
7
5
7
2
7

Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

128

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I
50
51
52
53
54
55
56
57
58
59
60
61
62
63
64
65
66
67
68
69
70
71
72
73
74
75
76
77
78
79
80
81
82
83
84
85
86
87

Column_Name
DUP_OVERRIDE_IND
ENCOUNTER_STATUS
PLACE_OF_SVC
ADMIT_HOUR
DISCHARG_HOUR
RX_ORDER_DT
NBR_THIS_REFILL
REFILLS_AUTH
MEDICARE_ALLOW_AMT
MEDICARE_DEDUCTIBLE
MEDICARE_PAYMENT
ICD9_PROC_CODE_1
ICD9_PROC_DATE_1
ICD9_PROC_CODE_2
ICD9_PROC_DATE_2
ICD9_PROC_CODE_3
ICD9_PROC_DATE_3
ICD9_PROC_CODE_4
ICD9_PROC_DATE_4
ICD9_PROC_CODE_5
ICD9_PROC_DATE_5
CO_INSURANCE
DIAGNOSIS_CD_1
DIAGNOSIS_CD_2
DIAGNOSIS_CD_3
DIAGNOSIS_CD_4
DIAGNOSIS_CD_5
DIAGNOSIS_CD_6
DIAGNOSIS_CD_7
DIAGNOSIS_CD_8
ADMIT_DIAG_CD
TRAUMA_DIAG_CD
REVENUE_CD
NON_COVERED_CHG
ICD9_CODE_2
ICD9_CODE_3
ICD9_CODE_4
PROVIDER_ID

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type
VARCHAR2
VARCHAR2
VARCHAR2
NUMBER
NUMBER
DATE
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
NUMBER
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
NUMBER
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2

Data Length Null?
1
2
2
2,0
2,0
7
2,0
2,0
8,2
8,2
8,2
4
4
4
4
4
4
4
4
4
4
9,2
6
6
6
6
6
6
6
6
6
6
4
10,2
6
6
6
6

Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

129

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I

Column_Name

88
PROV_LOCATOR_CD
89
GROUP_BILLER_ID
90
GROUP_LOCATOR_CD
Table Name:
ENCOUNTER_ARCH_TMP
1
ICN_NBR
2
LINE_NBR
3
CHANGE_SEQ_NBR
4
PRIOR_AUTH_NBR
5
CLIENT_ID
6
PROCEDURE_CODE
7
CONTR_ID
8
SUB_CONTR_ID
9
FACILITY_ID
10
START_DT
11
END_DT
12
ADJUSTMENT_FLAG
13
SVC_TYPE
14
DIAGNOSIS_CODE
15
UNIT_OF_SERVICE
16
ALLOWABLE_CHARGE
17
PATIENT_STATUS
18
ATTENDING_PHYSICIAN
19
ADMISSION_TYPE
20
ADMISSION_DT
21
BILL_TYPE
22
NDC_CODE
23
ENCOUNTER_PENDING
24
CRN_NBR
25
EDS_ADD_DT
26
EDS_FILE_DT
27
CHANGE_CONTROL_DATE
28
AHCCCS_SEND_DT
29
NET_PAID
30
DISPENSE_QUANTITY
31
AHCCCS_LINE_NBR
32
ADJUSTMENT_ICN
33
SPECIAL_NET_VALUE
34
ENCOUNTER_FORM_TYPE

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type
VARCHAR2
VARCHAR2
VARCHAR2
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
DATE
DATE
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR

Data Length Null?
2
6
2

Y
Y
Y

11
2
4
6
10
5
2
4
3
7
7
1
1
6
8
8
2
9
1
9
3
11
1
14
9
9
9
9
8
4
2
11
8
1

N
N
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

130

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I

Column_Name

35
EDS_UPDATE_DT
36
CIS_ADD_DATE
37
CHANGE_CONTROL_PGM
38
CHANGE_CONTROL_USER_ID
39
ADMISSION_SOURCE
40
OCCURRENCE_CODE
41
OCCURRENCE_DATE
42
OTHER_INS_COV_FLAG
43
OTHER_INS_PAYMENT
44
PRIN_PROC_CODE
45
PRIN_PROC_DATE
46
OTHER_PROC_CODE
47
OTHER_PROC_DATE
48
MED_PROC_CODE_MODIFIER
49
ENCOUNTER_PROCESS_DT
50
DUP_OVERRIDE_IND
51
ENCOUNTER_STATUS
52
PLACE_OF_SVC
53
ADMIT_HOUR
54
DISCHARG_HOUR
55
RX_ORDER_DT
56
NBR_THIS_REFILL
57
REFILLS_AUTH
Table Name:
ENCOUNTER_FY9394A
1
ICN_NBR
2
LINE_NBR
3
CHANGE_SEQ_NBR
4
PRIOR_AUTH_NBR
5
CLIENT_ID
6
PROCEDURE_CODE
7
CONTR_ID
8
SUB_CONTR_ID
9
FACILITY_ID
10
START_DT
11
END_DT
12
ADJUSTMENT_FLAG
13
SVC_TYPE
14
DIAGNOSIS_CODE

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type

Data Length Null?

CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR

9
9
8
8
1
2
9
1
9
5
9
5
9
2
9
1
2
2
2
2
9
2
2

Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
DATE
DATE
CHAR
CHAR
CHAR

11
2
4
6
10
5
2
4
3
7
7
1
1
6

N
N
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

131

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
51
52

Column_Name
UNIT_OF_SERVICE
ALLOWABLE_CHARGE
PATIENT_STATUS
ATTENDING_PHYSICIAN
ADMISSION_TYPE
ADMISSION_DT
BILL_TYPE
NDC_CODE
ENCOUNTER_PENDING
CRN_NBR
EDS_ADD_DT
EDS_FILE_DT
CHANGE_CONTROL_DATE
AHCCCS_SEND_DT
NET_PAID
DISPENSE_QUANTITY
AHCCCS_LINE_NBR
ADJUSTMENT_ICN
SPECIAL_NET_VALUE
ENCOUNTER_FORM_TYPE
EDS_UPDATE_DT
CIS_ADD_DATE
CHANGE_CONTROL_PGM
CHANGE_CONTROL_USER_ID
ADMISSION_SOURCE
OCCURRENCE_CODE
OCCURRENCE_DATE
OTHER_INS_COV_FLAG
OTHER_INS_PAYMENT
PRIN_PROC_CODE
PRIN_PROC_DATE
OTHER_PROC_CODE
OTHER_PROC_DATE
MED_PROC_CODE_MODIFIER
ENCOUNTER_PROCESS_DT
DUP_OVERRIDE_IND
ENCOUNTER_STATUS
PLACE_OF_SVC

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR

Data Length Null?
8
8
2
9
1
9
3
11
1
14
9
9
9
9
8
4
2
11
8
1
9
9
8
8
1
2
9
1
9
5
9
5
9
2
9
1
2
2

Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

132

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I

Column_Name

53
ADMIT_HOUR
54
DISCHARG_HOUR
55
RX_ORDER_DT
56
NBR_THIS_REFILL
57
REFILLS_AUTH
Table Name:
ENCOUNTER_PEND
1
CRN_DATE
2
CRN_BATCH
3
CRN_DOC
4
CRN_LINE_NBR
5
CLAIM_TYPE
6
FORM_TYPE
7
CREATE_DT
8
HEALTH_PLAN
9
AHCCCS_ID
10
SVC_PROV_ID
11
PATIENT_ACCT_NBR
12
CHANGE_CONTROL_DT
13
AHCCCS_CRN_DATE
Table Name:
ENCOUNTER_PEND_DTL
1
CRN_DATE
2
CRN_BATCH
3
CRN_DOC
4
CRN_LINE_NBR
5
INVOICE_NBR
6
REC_TYPE
7
INTERNAL_FLD_NBR
8
OLD_VALUE
9
NEW_VALUE
10
ACTION_CD
11
CCL_LOC
12
FORM_FLD_NM
13
AHCCCS_CRN_DATE
Table Name:
ENCOUNTER_PEND_ERR
1
CRN_DATE
2
CRN_BATCH
3
CRN_DOC
4
CRN_LINE_NBR

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type
CHAR
CHAR
CHAR
CHAR
CHAR

Data Length Null?
2
2
9
2
2

Y
Y
Y
Y
Y

DATE
NUMBER
NUMBER
NUMBER
VARCHAR2
VARCHAR2
DATE
NUMBER
VARCHAR2
VARCHAR2
VARCHAR2
DATE
DATE

7
4,0
3,0
2,0
1
1
7
6,0
9
6
17
7
7

N
N
N
N
Y
Y
Y
Y
Y
Y
Y
Y
N

DATE
NUMBER
NUMBER
NUMBER
NUMBER
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
DATE

7
4,0
3,0
2,0
6,0
2
3
17
17
1
2
15
7

N
N
N
N
N
N
Y
Y
Y
Y
Y
Y
N

DATE
NUMBER
NUMBER
NUMBER

7
4,0
3,0
2,0

N
N
N
N

133

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I

Column_Name

5
REC_TYPE
6
ERR_CD_01
7
ERR_CD_02
8
ERR_CD_03
9
ERR_CD_04
10
ERR_CD_05
11
ERR_CD_06
12
ERR_CD_07
13
ERR_CD_08
14
ERR_CD_09
15
ERR_CD_10
16
ERR_CD_11
17
ERR_CD_12
18
ERR_CD_13
19
ERR_CD_14
20
ERR_CD_15
21
AHCCCS_CRN_DATE
Table Name:
ENROLL_MODS
1
CONTR_ID
2
CLIENT_ID
3
ASSESS_DT
4
OLD_CLIENT_TYPE
5
NEW_CLIENT_TYPE
6
OLD_AHCCCS_ID
7
NEW_AHCCCS_ID
8
OLD_OTHER_AGENCYS
9
NEW_OTHER_AGENCYS
10
OLD_MHS_CAT
11
NEW_MHS_CAT
12
OLD_DES_DD_INDICATOR
13
NEW_DES_DD_INDICATOR
14
TRAN_TYPE
15
START_DT
16
END_DT
17
CLOSURE_REASON
18
INTAKE_DATE
19
CHANGE_CONTROL_DATE
20
CHANGE_CONTROL_PGM

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type

Data Length Null?

VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
DATE

2
4
4
4
4
4
4
4
4
4
4
4
4
4
4
4
7

N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
N

VARCHAR2
VARCHAR2
DATE
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
DATE
DATE
VARCHAR2
DATE
DATE
VARCHAR2

2
10
7
1
1
9
9
3
3
1
1
1
1
1
7
7
2
7
7
8

N
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

134

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I

Column_Name

21
CHANGE_CONTROL_USER_ID
22
BYPASS_FLAG
Table Name:
ERROR_FIELD_XREF
1
ERROR_NBR
2
FIELD_NBR
Table Name:
ERROR_REPORT_PARAMETERS
1
ERROR_CODE
2
CONTROL_PROGRAM
3
NEW_STATUS
4
HEADING
5
COMMENT_TEXT
Table Name:
ERROR_STATS
1
CONTR_ID
2
SUB_CONTR_ID
3
FACILITY_ID
4
FORM_TYPE
5
ERROR_NUMBER
6
REPORT_RUN_DATE
7
COUNT
Table Name:
ERROR_TEXT
1
ERROR_NBR
2
ERROR_MESSAGE
Table Name:
FORM_FIELDS
1
FORM_NBR
2
FIELD_NBR
3
FIELD_DESC
Table Name:
GROUP_APPL_XREF
1
GROUP_ID
2
APPLICATION_ID
Table Name:
GROUP_PROVIDER_XREF
1
GROUP_ID
2
CONTR_ID
3
SUB_CONTR_ID
4
FACILITY_ID
Table Name:
H74_APPLICATION
1
APPLICATION_ID
2
APPLICATION_DESCRIPTION

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type
VARCHAR2
VARCHAR2

Data Length Null?
8
1

Y
Y

NUMBER
NUMBER

4,0
2,0

N
N

VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2

2
8
2
50
80

N
Y
Y
Y
Y

VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
NUMBER
DATE
NUMBER

2
4
3
4
4,0
7
5,0

Y
Y
Y
Y
Y
Y
Y

NUMBER
VARCHAR2

4,0
79

N
N

NUMBER
NUMBER
VARCHAR2

2,0
2,0
15

N
N
Y

VARCHAR2
VARCHAR2

30
7

N
N

VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2

30
2
4
3

N
N
N
N

VARCHAR2
VARCHAR2

7
65

Y
Y

135

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I

Column_Name

Table Name:
H74_CIS_VERSION
1
SYSTEM
2
VERSION_NBR
3
VERSION_DATE
4
IP_ADDRESS
5
USERID
6
PASSWORD
7
SOURCEFILE
8
TARGETFILE
Table Name:
H74_CLIENT_DUMMY_ID
1
CONTR_ID
2
CLIENT_ID
3
START_DATE
4
END_DATE
5
CHANGE_CONTROL_DATE
6
CHANGE_CONTROL_USER_ID
7
SYS_ADD_DATE
Table Name:
H74_CLIENT_YEARLY_TOTALS
1
CLIENT_ID
2
TYPE
3
FIN_YEAR
4
VALUE
5
AGE_21_FLAG
6
DAYS_SENT_TO_AHCCCS
Table Name:
H74_DOC_CHAIN
1
CHAIN_NAME
2
DESCRIPTION
Table Name:
H74_DOC_CHAINMODULE
1
CHAIN_NAME
2
MODULE_ORDER
3
MODULE_NAME
Table Name:
H74_DOC_INDEX
1
TABLE_NAME
2
INDEX_NAME
Table Name:
H74_DOC_LASTUPDATE
1
LAST_UPDATE

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type

Data Length Null?

VARCHAR2
VARCHAR2
DATE
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2

10
5
7
16
10
10
20
20

Y
Y
Y
Y
Y
Y
Y
Y

VARCHAR2
VARCHAR2
DATE
DATE
DATE
VARCHAR2
DATE

2
10
7
7
7
10
7

N
N
N
Y
Y
Y
Y

VARCHAR2
VARCHAR2
VARCHAR2
NUMBER
VARCHAR2
NUMBER

10
3
4
10,2
1
3,0

N
N
N
Y
Y
Y

VARCHAR2
VARCHAR2

30
30

N
Y

VARCHAR2
NUMBER
VARCHAR2

30
5,0
30

N
N
Y

VARCHAR2
VARCHAR2

30
30

N
N

7

Y

DATE

136

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual

Column_I

Column_Name

Table Name:
H74_DOC_MODULE
1
MODULE_NAME
2
TYPE
3
DESCRIPTION
Table Name:
H74_DOC_MODULECHAIN
1
MODULE_NAME
2
CHAIN_NAME
Table Name:
H74_DOC_MODULEPROMPT
1
MODULE_NAME
2
OBJECT_NAME
3
PROMPT
4
DESCRIPTION
5
DEFAULT_VALUE
Table Name:
H74_DOC_MODULESHELL
1
MODULE_NAME
2
SHELL_NAME
Table Name:
H74_DOC_MODULESQL
1
MODULE_NAME
2
SQL_NAME
Table Name:
H74_DOC_PROGRAM
1
PROGRAM_NAME
Table Name:
H74_DOC_PROGRAMTABLE
1
PROGRAM_NAME
2
TABLE_NAME
Table Name:
H74_DOC_SHELL
1
SHELL_NAME
Table Name:
H74_DOC_SHELLPROGRAM
1
SHELL_NAME
2
PROGRAM_NAME
Table Name:
H74_DOC_SHELLSQL
1
SHELL_NAME
2
SQL_NAME
Table Name:
H74_DOC_SQL
1
SQL_NAME

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type

Data Length Null?

VARCHAR2
VARCHAR2
VARCHAR2

30
10
30

N
Y
Y

VARCHAR2
VARCHAR2

30
30

N
N

VARCHAR2
VARCHAR2
NUMBER
VARCHAR2
VARCHAR2

30
30
12,0
50
512

N
Y
N
Y
Y

VARCHAR2
VARCHAR2

30
30

N
N

VARCHAR2
VARCHAR2

30
30

N
N

VARCHAR2

30

N

VARCHAR2
VARCHAR2

30
30

N
N

VARCHAR2

30

N

VARCHAR2
VARCHAR2

30
30

N
Y

VARCHAR2
VARCHAR2

30
30

N
N

VARCHAR2

30

N

137

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I

Column_Name

Table Name:
H74_DOC_TABLE
1
TABLE_NAME
2
OWNER
Table Name:
H74_DOC_TABLECOLUMN
1
TABLE_NAME
2
COLUMN_NAME
Table Name:
H74_DOC_VIEW
1
VIEW_NAME
Table Name:
H74_ESTR
1
SERVICE_MONTH
2
ENCOUNTER_FORM_TYPE
3
ESTR_GROUP
4
AHCCCS_ELIG
5
ESTR_COUNT
6
CHANGE_CONTROL_DATE
Table Name:
H74_ESTR_GROUP
1
ESTR_GROUP
2
GROUP_ORDER
3
DESCRIPTION
Table Name:
H74_GROUP_APPL_XREF
1
GROUP_ID
2
APPLICATION_ID
3
GROUP_ACCESS
Table Name:
H74_INVALID_PROCEDURE_CODES
1
PROCEDURE_CODE
2
START_DATE
3
END_DATE
4
INVALID_PROC_CODE
5
CHANGE_CONTROL_DATE
6
CHANGE_CONTROL_USER_ID
7
SYS_ADD_DATE
Table Name:
H74_INVALID_REV_PROC_CODES
1
PROCEDURE_CODE
2
REVENUE_CODE
3
PROVIDER_TYPE
4
START_DATE
5
END_DATE
6
CHANGE_CONTROL_DATE

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type

Data Length Null?

VARCHAR2
VARCHAR2

30
15

N
Y

VARCHAR2
VARCHAR2

30
30

N
N

VARCHAR2

30

N

DATE
VARCHAR2
VARCHAR2
VARCHAR2
NUMBER
DATE

7
1
3
4
8,0
7

N
N
N
N
Y
Y

VARCHAR2
NUMBER
VARCHAR2

3
5,0
50

N
Y
Y

VARCHAR2
VARCHAR2
VARCHAR2

30
7
10

N
N
N

VARCHAR2
DATE
DATE
VARCHAR2
DATE
VARCHAR2
DATE

5
7
7
5
7
10
7

N
N
Y
N
Y
Y
Y

VARCHAR2
VARCHAR2
VARCHAR2
DATE
DATE
DATE

5
3
2
7
7
7

N
N
N
N
Y
Y

138

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I

Column_Name

7
CHANGE_CONTROL_USER_ID
8
SYS_ADD_DATE
9
BOTH_SVC_ALLOWED
Table Name:
H74_INVALID_REVENUE_CODES
1
REVENUE_CODE
2
PROVIDER_TYPE
3
START_DATE
4
INVALID_REV_CODE
5
END_DATE
6
CHANGE_CONTROL_DATE
7
CHANGE_CONTROL_USER_ID
8
SYS_ADD_DATE
Table Name:
H74_MAX_TYPE_LIMITS
1
TYPE
2
START_DATE
3
END_DATE
4
MAX_VALUE
5
TYPE_DESCRIPTION
Table Name:
H74_PROCEDURE_COS
1
PROCEDURE_CODE
2
CATEGORY_OF_SVC
3
START_DATE
4
END_DATE
Table Name:
H74_PROCEDURE_COVERAGE
1
PROCEDURE_CODE
2
COVERAGE_CODE
3
START_DATE
4
REPLACEMENT_PROC_CODE
5
END_DATE
Table Name:
H74_PROCEDURE_MAC
1
PROCEDURE_CODE
2
COUNTY
3
START_DATE
4
END_DATE
5
MAC
Table Name:
H74_PROCEDURE_MODIFIER
1
PROCEDURE_CODE
2
PROCEDURE_MODIFIER

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type

Data Length Null?

VARCHAR2
DATE
VARCHAR2

10
7
1

Y
Y
Y

VARCHAR2
VARCHAR2
DATE
VARCHAR2
DATE
DATE
VARCHAR2
DATE

3
2
7
3
7
7
10
7

N
N
N
N
Y
Y
Y
Y

VARCHAR2
DATE
DATE
NUMBER
VARCHAR2

3
7
7
10,2
30

N
N
Y
Y
Y

VARCHAR2
VARCHAR2
DATE
DATE

5
2
7
7

N
N
N
Y

VARCHAR2
VARCHAR2
DATE
VARCHAR2
DATE

5
2
7
5
7

N
N
N
Y
Y

VARCHAR2
VARCHAR2
DATE
DATE
NUMBER

5
2
7
7
11,2

N
N
N
Y
N

VARCHAR2
VARCHAR2

5
2

N
N

139

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I

Column_Name

3
START_DATE
4
END_DATE
5
PAYMENT_TYPE
6
AMOUNT
7
CLAIM_RECEIPT
Table Name:
H74_PROCEDURE_POS
1
PROCEDURE_CODE
2
PLACE_OF_SERVICE
3
START_DATE
4
END_DATE
5
CHANGE_CONTROL_DATE
6
CHANGE_CONTROL_USER_ID
7
SYS_ADD_DATE
Table Name:
H74_REFERENCE_H1
1
PROCEDURE_CODE
2
DESCRIPTION
3
MIN_AGE
4
MIN_AGE_TYPE
5
MAX_AGE
6
MAX_AGE_TYPE
7
RECORD_TYPE
8
CHANGE_CONTROL_DATE
Table Name:
H74_REFERENCE_H2
1
PROCEDURE_CODE
2
COUNTY
3
BEGIN_DATE
4
END_DATE
5
MAC
6
CRN_DATE
7
RECORD_TYPE
Table Name:
H74_REFERENCE_H3
1
PROCEDURE_CODE
2
COVERAGE_CODE
3
REPLACEMENT_PROC_CODE
4
BEGIN_DATE
5
END_DATE
6
RECORD_TYPE
7
CHANGE_CONTROL_DATE

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type

Data Length Null?

DATE
DATE
VARCHAR2
NUMBER
VARCHAR2

7
7
1
11,4
8

N
Y
Y
Y
Y

VARCHAR2
VARCHAR2
DATE
DATE
DATE
VARCHAR2
DATE

5
2
7
7
7
10
7

N
N
N
Y
Y
Y
Y

VARCHAR2
VARCHAR2
NUMBER
VARCHAR2
NUMBER
VARCHAR2
VARCHAR2
DATE

5
65
3,0
1
3,0
1
2
7

N
Y
Y
Y
Y
Y
Y
Y

VARCHAR2
VARCHAR2
DATE
DATE
NUMBER
DATE
VARCHAR2

5
2
7
7
11,2
7
2

N
Y
Y
Y
Y
Y
Y

VARCHAR2
VARCHAR2
VARCHAR2
DATE
DATE
VARCHAR2
DATE

5
2
5
7
7
2
7

N
Y
Y
Y
Y
Y
Y

140

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I

Column_Name

Table Name:
H74_REVENUE_COS
1
REVENUE_CODE
2
CATEGORY_OF_SVC
3
START_DATE
4
END_DATE
Table Name:
H74_REVENUE_PROCEDURE
1
PROCEDURE_CODE
2
REVENUE_CODE
3
PROVIDER_TYPE
4
START_DATE
5
END_DATE
Table Name:
H74_SENT
1
SENT_USERID
2
SENT_PARAMETER
3
SENT_ADD_DATE
4
SENT_MOD_DATE
5
SENT_MOD_USER
Table Name:
H74_TRANS_CODES
1
PROCEDURE_CODE
2
START_DATE
3
END_DATE
4
PROCEDURE_NAME
Table Name:
H74_UNAPPROVED_RBHAS
1
RBHA_ID
2
FORM_TYPE
Table Name:
H74_USER_ENV
1
USER_ID
2
VERSION_NBR
3
UPGRADE_DATE
4
OS_VERSION
Table Name:
H74_USER_SETUP
1
USER_ID
2
L_NM
3
F_NM
4
PASSWORD
5
PASSWORD_DATE
6
GROUP_ID
7
LOCK_COUNT

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type

Data Length Null?

VARCHAR2
VARCHAR2
DATE
DATE

5
2
7
7

N
N
N
Y

VARCHAR2
VARCHAR2
VARCHAR2
DATE
DATE

5
3
2
7
7

N
N
Y
Y
Y

VARCHAR2
VARCHAR2
DATE
DATE
VARCHAR2

2048
2048
7
7
10

N
N
N
N
N

VARCHAR2
DATE
DATE
VARCHAR2

5
7
7
65

N
Y
Y
N

VARCHAR2
VARCHAR2

2
1

Y
Y

VARCHAR2
VARCHAR2
DATE
VARCHAR2

30
10
7
30

N
Y
Y
Y

VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
DATE
VARCHAR2
NUMBER

30
15
10
10
7
30
2,0

Y
Y
Y
Y
Y
Y
Y

141

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I

Column_Name

8
RBHA_ID
9
CHG_CTRL_DT
10
CHG_CTRL_USER
Table Name:
H74130_CONTROL
1
SARA_RUN_DATE_MM
2
SARA_RUN_DATE_DD
3
SARA_RUN_DATE_YY
4
SARA_NUMBER_OF_DAYS
5
SARA_CONTR_ID
6
SARA_CONTR_NAME
7
SARA_T19_CHILDREN
8
SARA_NON_T19_CHILDREN
9
SARA_SUB_TOTAL_CHILDREN
10
SARA_T19_SMI
11
SARA_NON_T19_SMI
12
SARA_SUB_TOTAL_SMI
13
SARA_T19_GMH
14
SARA_GENERAL_MENTAL_HEALTH
15
SARA_T19_ALC
16
SARA_ALCOHOL_ABUSE
17
SARA_T19_DRG
18
SARA_DRUG_ABUSE
19
SARA_OTHER_PROGRAMS
20
SARA_SUB_TOTAL_NON_SMI
21
SARA_GRAND_TOTALS
Table Name:
H74130_CONTROL2
1
SARA_RUN_DATE_MM
2
SARA_RUN_DATE_DD
3
SARA_RUN_DATE_YY
4
SARA_NUMBER_OF_DAYS
5
SARA_CONTR_ID
6
SARA_CONTR_NAME
7
SARA_T19_CHILDREN
8
SARA_NON_T19_CHILDREN
9
SARA_SUB_TOTAL_CHILDREN
10
SARA_T19_SMI
11
SARA_NON_T19_SMI
12
SARA_SUB_TOTAL_SMI

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type

Data Length Null?

VARCHAR2
DATE
VARCHAR2

10
7
30

Y
Y
Y

VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2

2
2
2
3
2
10
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6

Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2

2
2
2
3
2
10
6
6
6
6
6
6

Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

142

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I

Column_Name

13
SARA_T19_GMH
14
SARA_GENERAL_MENTAL_HEALTH
15
SARA_T19_ALC
16
SARA_ALCOHOL_ABUSE
17
SARA_T19_DRG
18
SARA_DRUG_ABUSE
19
SARA_OTHER_PROGRAMS
20
SARA_SUB_TOTAL_NON_SMI
21
SARA_GRAND_TOTALS
Table Name:
H74130T_CONTROL
1
SARA_RUN_DATE_MM
2
SARA_RUN_DATE_DD
3
SARA_RUN_DATE_YY
4
SARA_NUMBER_OF_DAYS
5
SARA_CONTR_ID
6
SARA_CONTR_NAME
7
SARA_T19_CHILDREN
8
SARA_NON_T19_CHILDREN
9
SARA_SUB_TOTAL_CHILDREN
10
SARA_T19_SMI
11
SARA_NON_T19_SMI
12
SARA_SUB_TOTAL_SMI
13
SARA_T19_GMH
14
SARA_GENERAL_MENTAL_HEALT
15
SARA_T19_ALC
16
SARA_ALCOHOL_ABUSE
17
SARA_T19_DRG
18
SARA_DRUG_ABUSE
19
SARA_OTHER_PROGRAMS
20
SARA_SUB_TOTAL_NON_SMI
21
SARA_GRAND_TOTALS
Table Name:
H74130T_CONTROL2
1
SARA_RUN_DATE_MM
2
SARA_RUN_DATE_DD
3
SARA_RUN_DATE_YY
4
SARA_NUMBER_OF_DAYS
5
SARA_CONTR_ID
6
SARA_CONTR_NAME

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type

Data Length Null?

VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2

6
6
6
6
6
6
6
6
6

Y
Y
Y
Y
Y
Y
Y
Y
Y

VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2

2
2
2
3
2
10
6
6
6
6
6
6
6
6
6
6
6
6
6
6
6

Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2

2
2
2
3
2
10

Y
Y
Y
Y
Y
Y

143

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I

Column_Name

7
SARA_T19_CHILDREN
8
SARA_NON_T19_CHILDREN
9
SARA_SUB_TOTAL_CHILDREN
10
SARA_T19_SMI
11
SARA_NON_T19_SMI
12
SARA_SUB_TOTAL_SMI
13
SARA_T19_GMH
14
SARA_GENERAL_MENTAL_HEALT
15
SARA_T19_ALC
16
SARA_ALCOHOL_ABUSE
17
SARA_T19_DRG
18
SARA_DRUG_ABUSE
19
SARA_OTHER_PROGRAMS
20
SARA_SUB_TOTAL_NON_SMI
21
SARA_GRAND_TOTALS
Table Name:
H74156_CONTROL
1
WS_PX_CONTR_ID
2
WS_PX_NBR_CHILD_T19
3
WS_PX_NBR_CHILD_NON_T19
4
WS_PX_NBR_CHILD_SUBTOTAL
5
WS_PX_NBR_UNDUP_CHILD
6
WS_PX_NBR_SMI_T19
7
WS_PX_NBR_SMI_NON_T19
8
WS_PX_NBR_SMI_SUBTOTAL
9
WS_PX_NBR_UNDUP_SMI
10
WS_PX_NBR_GMH
11
WS_PX_NBR_GMH_NON_T19
12
WS_PX_NBR_DRUG
13
WS_PX_NBR_DRUG_NON_T19
14
WS_PX_NBR_ALCOHOL
15
WS_PX_NBR_ALCOHOL_NON_T19
16
WS_PX_NBR_OTHER_PROGRAMS
17
WS_PX_NBR_NONSMI_SUBTOTAL
18
WS_PX_NBR_UNDUP_NON_SMI
19
WS_PX_NBR_UNDUP_TOTAL_COUNT
Table Name:
H74156T_CONTROL
1
WS_PX_CONTR_ID
2
WS_PX_NBR_CHILD_T19

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type

Data Length Null?

VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2

6
6
6
6
6
6
6
6
6
6
6
6
6
6
6

Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2

2
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7

Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

VARCHAR2
VARCHAR2

2
7

Y
Y

144

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I

Column_Name

3
WS_PX_NBR_CHILD_NON_T19
4
WS_PX_NBR_CHILD_SUBTOTAL
5
WS_PX_NBR_UNDUP_CHILD
6
WS_PX_NBR_SMI_T19
7
WS_PX_NBR_SMI_NON_T19
8
WS_PX_NBR_SMI_SUBTOTAL
9
WS_PX_NBR_UNDUP_SMI
10
WS_PX_NBR_GMH
11
WS_PX_NBR_GMH_NON_T19
12
WS_PX_NBR_DRUG
13
WS_PX_NBR_DRUG_NON_T19
14
WS_PX_NBR_ALCOHOL
15
WS_PX_NBR_ALCOHOL_NON_T19
16
WS_PX_NBR_OTHER_PROGRAMS
17
WS_PX_NBR_NONSMI_SUBTOTAL
18
WS_PX_NBR_UNDUP_NON_SMI
19
WS_PX_NBR_UNDUP_TOTAL_COUNT
Table Name:
H74200_PROGRAM_CONTROL
1
PGM_ID
2
PGM_COUNT
3
CIS_ADD_DATE
4
CHANGE_CONTROL_USER_ID
5
CHANGE_CONTROL_DATE
6
CONTR_ID
7
CHANGE_CONTROL_PGM
Table Name:
H74255_CAPITATION
1
TRANSACTION_NBR
Table Name:
H74PROV_ADDRESSES1
1
DE_PROVIDER_ID
2
ADDRESS_TYPE
3
LOCATOR_CODE
4
STR_1
5
STR_2
6
BEGIN_DATE
7
END_DATE
Table Name:
H74PROV_ADDRESSES2
1
DE_PROVIDER_ID
2
ADDRESS_TYPE

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type

Data Length Null?

VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2

7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7
7

Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

VARCHAR2
NUMBER
DATE
VARCHAR2
DATE
VARCHAR2
VARCHAR2

8
10,0
7
8
7
2
8

N
Y
N
Y
N
Y
Y

NUMBER

9,0

N

VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
DATE
DATE

6
1
2
25
25
7
7

Y
Y
Y
Y
Y
Y
Y

VARCHAR2
VARCHAR2

6
1

Y
Y

145

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I

Column_Name

3
LOCATOR_CODE
4
PAY_LOCATOR_CODE
5
CITY
6
COUNTY
7
STATE
8
ZIP
9
COUNTRY
10
BUSINESS_PHONE
11
EMERGENCY_PHONE
Table Name:
H74PROV_CATEGORIES
1
DE_PROVIDER_ID
2
CATEGORY
3
BEGIN_DATE
4
END_DATE
Table Name:
H74PROV_DEMOGRAPHICS
1
PROVIDER_ID
2
PROVIDER_NAME
3
PROVIDER_TYPE
4
IHS_INDICATOR
Table Name:
H74PROV_ENROLLMENTS
1
DE_PROVIDER_ID
2
STATUS_TYPE
3
STATUS
4
BEGIN_DATE
5
END_DATE
6
REPLACEMENT_ID
Table Name:
H74PROV_PROFILES
1
PROVIDER_TYPE
2
CATEGORY
3
MAND_OPT
4
SERVICE_FROM
5
SERVICE_TO
6
SERVICE_TYPE
7
EFFECTIVE_BEGIN_DATE
8
EFFECTIVE_END_DATE
Table Name:
INTKE_ERR2
1
CLIENT_ID
2
SSNO

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type

Data Length Null?

VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2

2
2
25
2
2
9
2
10
10

Y
Y
Y
Y
Y
Y
Y
Y
Y

VARCHAR2
VARCHAR2
DATE
DATE

6
2
7
7

Y
Y
Y
Y

VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2

6
25
2
1

N
Y
Y
Y

VARCHAR2
VARCHAR2
VARCHAR2
DATE
DATE
VARCHAR2

6
1
2
7
7
6

N
Y
Y
Y
Y
Y

VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
DATE
DATE

2
2
1
11
11
1
7
7

Y
Y
Y
Y
Y
Y
Y
Y

VARCHAR2
VARCHAR2

10
10

N
Y

146

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I

Column_Name

3
INTAKE_DATE
4
CONTR_ID
5
CHANGE_CONTROL_DATE
Table Name:
INTKE_ERR3
1
CLIENT_ID
2
SSNO
3
INTAKE_DATE
4
CONTR_ID
5
CHANGE_CONTROL_DATE
Table Name:
INTKE_ERROR
1
CLIENT_ID
2
INTAKE_DATE
3
AHCCCS_ID
4
SSNO
5
F_NM
6
M_NM
7
L_NM
8
DOB
9
SEX
10
RBHA_ID
Table Name:
INTKE_NOMATCH
1
CLIENT_ID
2
SSNO
3
CONTR_ID
4
INTAKE_DATE
Table Name:
INTKEMATCH
1
CLIENT_ID
2
SSNO
3
CONTR_ID
4
INTAKE_DATE
Table Name:
LEVEL3_PROV_TYPE
1
PROCEDURE_CODE
2
PROVIDER_TYPE
3
EFFECTIVE_DATE
4
END_DATE
Table Name:
MENU_APPL_XREF
1
MENU_ID
2
MENU_ORDER

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type

Data Length Null?

DATE
VARCHAR2
DATE

7
2
7

Y
N
Y

VARCHAR2
VARCHAR2
DATE
VARCHAR2
DATE

10
10
7
2
7

N
Y
Y
N
Y

VARCHAR2
DATE
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
DATE
VARCHAR2
VARCHAR2

10
7
9
10
10
1
15
7
1
10

Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

VARCHAR2
VARCHAR2
VARCHAR2
DATE

10
10
2
7

Y
Y
Y
Y

VARCHAR2
VARCHAR2
VARCHAR2
DATE

10
10
2
7

Y
Y
Y
Y

VARCHAR2
VARCHAR2
DATE
DATE

5
2
7
7

N
N
Y
Y

VARCHAR2
NUMBER

7
3,0

N
N

147

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I

Column_Name

3
APPLICATION_ID
4
APPLICATION_TYPE
Table Name:
MONTHLY_AHCCCS
1
AHCCCS_ID
2
PROC_DT
3
CONTRACT_TYPE
4
MHS_CAT
5
CAPITATION_CODE
6
CAPITATION_AMOUNT
7
NUMBER_DAYS_COVERED
8
PAYT_TO_DT
9
PAYT_FROM_DT
10
VOUCHER_NUMBER
11
CLIENT_NAME
12
CONTR_ID
13
CLIENT_ID
Table Name:
MULT_INTKE_NOMATCH
1
CONTR_ID
2
CLIENT_ID
3
IN1
4
ADD1
5
CI2
6
ADD2
7
SSNO
Table Name:
MULT_SEG
1
CONTR_ID
2
CLIENT_ID
3
INTAKE_DATE
4
SMI_FLAG
5
SED_FLAG
6
START_DT
7
END_DT
8
MHS_CAT
Table Name:
NABP_PROV_XREF
1
NABP_ID
2
CONTR_ID
3
SUB_CONTR_ID
4
FACILITY_ID

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type

Data Length Null?

VARCHAR2
VARCHAR2

7
1

Y
N

VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
NUMBER
NUMBER
DATE
DATE
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2

9
6
1
1
4
7,2
3,0
7
7
9
34
2
10

N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

VARCHAR2
VARCHAR2
DATE
DATE
DATE
DATE
VARCHAR2

2
10
7
7
7
7
10

N
N
N
Y
N
Y
Y

VARCHAR2
VARCHAR2
DATE
VARCHAR2
VARCHAR2
DATE
DATE
VARCHAR2

2
10
7
1
1
7
7
1

Y
Y
Y
Y
Y
Y
Y
Y

VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2

7
2
4
3

N
N
N
N

148

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I

Column_Name

Table Name:
NIDA_SERVICES
1
PROCEDURE_CODE
2
PROVIDER_TYPE
3
CDS_SERVICE_CODE
Table Name:
OUT_STATE_PROVIDER
1
DHS_NUMBER
2
PROVIDER_NAME
3
DHS_TYPE
4
AHCCCS_NUMBER
5
AHCCCS_TYPE
6
START_DT
7
END_DT
8
CONTRACT_RBHA_CNTY_CD
Table Name:
PEND_ERROR_CODES
1
PEND_ERROR_CODE
Table Name:
PGM_MSGS_REF
1
PGM_ID
2
MSG_ID
3
MSG_TEXT
Table Name:
PROC_REPORT_CATEGORY
1
PROC_REPORT_CATEGORY
2
PROC_REPORT_DESCR
3
PROC_REPORT_SORT_ORDER
4
PROC_REPORT_OCCURRENCE
Table Name:
PROCEDURE_CODE
1
PROCEDURE_CODE
2
START_DATE
3
END_DATE
4
PROCEDURE_NAME
5
CDS_SERVICE_CODE
6
SUBVENTION_ONLY_FLAG
7
REPORT_CATEGORY
8
UNIT_MULTIPLIER
9
SEX
10
XXI_FLAG
11
MIN_AGE
12
MIN_AGE_TYPE
13
MAX_AGE

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type

Data Length Null?

VARCHAR2
VARCHAR2
VARCHAR2

5
2
2

N
N
N

VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
DATE
DATE
VARCHAR2

9
31
2
9
2
7
7
2

Y
Y
Y
Y
Y
Y
Y
Y

VARCHAR2

4

Y

VARCHAR2
VARCHAR2
VARCHAR2

8
4
80

N
N
Y

VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2

2
40
2
15

N
N
N
N

VARCHAR2
DATE
DATE
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
NUMBER
VARCHAR2
VARCHAR2
NUMBER
VARCHAR2
NUMBER

5
7
7
65
1
1
2
5,2
1
1
3,0
1
3,0

N
Y
Y
N
Y
Y
Y
Y
Y
Y
Y
Y
Y

149

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I

Column_Name

14
MAX_AGE_TYPE
15
MAX_DAILY_UNIT
16
FREQUENCY_VALUE
17
FREQUENCY_CODE
18
ANESTHESIA_MAX
19
ANESTHESIA_VALUE
20
FOLLOW_UP
21
MIN_AGE_QUALIFIER
22
MAX_AGE_QUALIFIER
23
MEDICARE_INDICATOR
24
CHANGE_CONTROL_DATE
25
CHANGE_CONTROL_USER_ID
26
SYS_ADD_DATE
27
DUMMY_ID_ONLY
28
DUMMY_ID_ALLOWED
29
ANOTHER_PROV_BILL
Table Name:
PROCEDURE_UNIT
1
PROCEDURE_CODE
2
RATE_SEQ
3
TIMESTAMP
4
MAX_UNITS
5
UNIT_EFFECTIVE_DATE
6
UNIT_END_DATE
7
PRIOR_AUTH_IND
8
AUTH_EFFECTIVE_DATE
9
AUTH_END_DATE
Table Name:
PROD_COS
1
AHCCCS_ID
2
PROVIDER_ID
3
PROVIDER_COS
4
START_DT
5
END_DT
6
CHANGE_CONTROL_DATE
7
CHANGE_CONTROL_USER_ID
8
AHCCCS_MATCH_FLAG
Table Name:
PROD_ENROLL
1
AHCCCS_ID
2
PROVIDER_ID

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type

Data Length Null?

VARCHAR2
NUMBER
VARCHAR2
VARCHAR2
VARCHAR2
NUMBER
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
DATE
VARCHAR2
DATE
VARCHAR2
VARCHAR2
VARCHAR2

1
3,0
3
1
4
4,1
3
1
1
1
7
10
7
2
2
1

Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

VARCHAR2
NUMBER
DATE
NUMBER
DATE
DATE
VARCHAR2
DATE
DATE

5
4,0
7
3,0
7
7
1
7
7

N
N
N
Y
Y
Y
Y
Y
Y

VARCHAR2
VARCHAR2
VARCHAR2
DATE
DATE
DATE
VARCHAR2
VARCHAR2

9
9
2
7
7
7
30
1

N
N
N
N
Y
Y
Y
N

VARCHAR2
VARCHAR2

9
9

N
N

150

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I

Column_Name

3
START_DT
4
END_DT
5
AHCCCS_PROV_TYPE
6
CHANGE_CONTROL_DATE
7
CHANGE_CONTROL_USER_ID
8
AHCCCS_MATCH_FLAG
9
AHCCCS_ENROLL_STAT
Table Name:
PROD_PROVIDER
1
CONTR_ID
2
SUB_CONTR_ID
3
FACILITY_ID
4
START_DT
5
END_DT
6
PROVIDER_NM_FIRST
7
PROVIDER_NM_LAST
8
PROVIDER_PAYEE_NAME
9
ADDRESS_1
10
ADDRESS_2
11
CITY
12
STATE
13
ZIP_5
14
ZIP_4
15
COUNTY
16
PHONE_NBR
17
GROUP_ID
18
SOC_SEC_NO
19
TAX_ID
20
FISCAL_YEAR_MONTH_END
21
FISCAL_YEAR_DAY_END
22
PROVIDER_TYPE
23
GROUP_CODE
24
LICENSE
25
EPSDT
26
NUMBER_OF_BEDS
27
PROVIDER_SHORT_NM
28
CENSUS_PLACE
29
CENSUS_TRACT
30
DNHS_CODE

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type

Data Length Null?

DATE
DATE
VARCHAR2
DATE
VARCHAR2
VARCHAR2
VARCHAR2

7
7
2
7
30
1
1

N
Y
Y
Y
Y
N
N

VARCHAR2
VARCHAR2
VARCHAR2
DATE
DATE
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
NUMBER
NUMBER
NUMBER
NUMBER
VARCHAR2
NUMBER
VARCHAR2
NUMBER
NUMBER
VARCHAR2
NUMBER
VARCHAR2
VARCHAR2
NUMBER
VARCHAR2
NUMBER
NUMBER
NUMBER

2
4
3
7
7
25
25
31
25
25
15
2
5,0
4,0
2,0
10,0
9
9,0
12
2,0
2,0
2
2,0
10
1
5,0
10
4,0
6,2
8,0

Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

151

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I

Column_Name

31
CDS_ID
32
NDATUS_ID
33
NDATUS_START_DATE
34
NDATUS_OBSOLETE_DATE
35
AHCCCS_ID
36
AHCCCS_TYPE
37
EDS_UPDATE_ID
38
EDS_UPDATE_DT
39
EDS_FILE_DT
40
CHANGE_CONTROL_DATE
41
CHANGE_CONTROL_USER_ID
42
CDS_START_DATE
43
CDS_OBSOLETE_DATE
44
EDS_ADD_DT
45
CIS_ADD_DATE
46
CHANGE_CONTROL_PGM
47
FAX_NBR
Table Name:
PROGRAM
1
PROGRAM_CODE
2
START_DT
3
END_DT
4
PROGRAM_TYPE
5
PROGRAM_DESCR
6
CAPITATED_IND
7
COST_CENTER
8
TOTAL_BUDGETED_AMOUNT
9
ALLOCATED_AMOUNT
10
RESERVED_AMOUNT
11
DISBURSED_AMOUNT
Table Name:
PROGRAM_BUDGET_DETAIL
1
PROGRAM_CODE
2
SEQUENCE_NBR
3
START_DT
4
END_DT
5
RESTRICTION_CODE
6
TOTAL_BUDGETED_AMOUNT
7
ALLOCATED_AMOUNT
8
DISBURSED_AMOUNT

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type

Data Length Null?

VARCHAR2
VARCHAR2
DATE
DATE
VARCHAR2
VARCHAR2
VARCHAR2
DATE
DATE
DATE
VARCHAR2
DATE
DATE
DATE
DATE
VARCHAR2
NUMBER

15
15
7
7
9
2
8
7
7
7
30
7
7
7
7
8
10,0

Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

VARCHAR2
DATE
DATE
VARCHAR2
VARCHAR2
VARCHAR2
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER

1
7
7
1
50
1
6,0
9,0
9,2
9,2
9,2

N
N
N
Y
Y
Y
Y
Y
Y
Y
Y

VARCHAR2
NUMBER
DATE
DATE
VARCHAR2
NUMBER
NUMBER
NUMBER

1
3,0
7
7
2
9,0
9,2
9,2

N
N
N
N
Y
Y
Y
Y

152

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I

Column_Name

Table Name:
PROGRAM_FUND_TYPE
1
PROGRAM_CODE
2
FUND_TYPE
3
START_DT
4
END_DT
Table Name:
PROV_PROFILE
1
AHCCCS_PROV_TYPE
2
PROVIDER_COS
3
SER_CODE_FROM
4
SER_CODE_TO
5
COS_MAN_OPT
6
SER_TYPE
7
CHANGE_CONTROL_DATE
8
CHANGE_CONTROL_USER_ID
Table Name:
PROVIDER
1
CONTR_ID
2
SUB_CONTR_ID
3
FACILITY_ID
4
START_DT
5
END_DT
6
PROVIDER_NM_FIRST
7
PROVIDER_NM_LAST
8
PROVIDER_PAYEE_NAME
9
ADDRESS_1
10
ADDRESS_2
11
CITY
12
STATE
13
ZIP_5
14
ZIP_4
15
COUNTY
16
PHONE_NBR
17
GROUP_ID
18
SOC_SEC_NO
19
TAX_ID
20
FISCAL_YEAR_MONTH_END
21
FISCAL_YEAR_DAY_END
22
PROVIDER_TYPE
23
GROUP_CODE

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type

Data Length Null?

VARCHAR2
VARCHAR2
DATE
DATE

1
2
7
7

N
N
Y
Y

VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
DATE
VARCHAR2

2
2
11
11
1
1
7
30

Y
Y
Y
Y
Y
Y
Y
Y

VARCHAR2
VARCHAR2
VARCHAR2
DATE
DATE
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
NUMBER
NUMBER
NUMBER
NUMBER
VARCHAR2
NUMBER
VARCHAR2
NUMBER
NUMBER
VARCHAR2
NUMBER

2
4
3
7
7
25
25
31
25
25
15
2
5,0
4,0
2,0
10,0
9
9,0
12
2,0
2,0
2
2,0

Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

153

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I

Column_Name

24
LICENSE
25
EPSDT
26
NUMBER_OF_BEDS
27
PROVIDER_SHORT_NM
28
CENSUS_PLACE
29
CENSUS_TRACT
30
DNHS_CODE
31
CDS_ID
32
NDATUS_ID
33
NDATUS_START_DATE
34
NDATUS_OBSOLETE_DATE
35
AHCCCS_ID
36
AHCCCS_TYPE
37
EDS_UPDATE_ID
38
EDS_UPDATE_DT
39
EDS_FILE_DT
40
CHANGE_CONTROL_DATE
41
CHANGE_CONTROL_USER_ID
42
CDS_START_DATE
43
CDS_OBSOLETE_DATE
44
EDS_ADD_DT
45
CIS_ADD_DATE
46
CHANGE_CONTROL_PGM
47
FAX_NBR
Table Name:
PROVIDER_TYPE
1
PROVIDER_TYPE
2
DESCR
Table Name:
RBHA_BUDGET_DTL_COMPONENT
1
CONTR_ID
2
PROGRAM_CODE
3
RESTRICTION_CODE
4
DIVISION_CODE
5
FUNDING_SOURCE
6
ACTIVITY_CODE
7
FUND_START_DT
8
FUND_END_DT
9
AMOUNT

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type

Data Length Null?

VARCHAR2
VARCHAR2
NUMBER
VARCHAR2
NUMBER
NUMBER
NUMBER
VARCHAR2
VARCHAR2
DATE
DATE
VARCHAR2
VARCHAR2
VARCHAR2
DATE
DATE
DATE
VARCHAR2
DATE
DATE
DATE
DATE
VARCHAR2
NUMBER

10
1
5,0
10
4,0
6,2
8,0
15
15
7
7
9
2
8
7
7
7
30
7
7
7
7
8
10,0

Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

VARCHAR2
VARCHAR2

2
40

N
N

VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
DATE
DATE
NUMBER

2
1
2
2
2
6
7
7
9,2

N
N
N
N
N
N
Y
Y
Y

154

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I

Column_Name

Table Name:
RBHA_PROGRAM
1
CONTR_ID
2
PROGRAM_CODE
3
START_DT
4
END_DT
5
TOTAL_BUDGETED_AMOUNT
6
ALLOCATED_AMOUNT
7
DISBURSED_AMOUNT
Table Name:
RBHA_PROGRAM_BUDGET_DETAIL
1
CONTR_ID
2
PROGRAM_CODE
3
SEQUENCE_NBR
4
START_DT
5
END_DT
6
RESTRICTION_CODE
7
TOTAL_BUDGETED_AMOUNT
8
ALLOCATED_AMOUNT
9
DISBURSED_AMOUNT
Table Name:
RESTRICTION_CODE
1
RESTRICTION_CODE
2
RESTRICTION_DESCR
Table Name:
RESTRICTION_CODE_DETAIL
1
RESTRICTION_CODE
2
SEQUENCE_NBR
3
RESTRICTION_TYPE
4
INTAKE_FORM_FIELD
5
INTAKE_FORM_VALUE
6
SERVICE_AUTH_FIELD
7
SERVICE_AUTH_VALUE
Table Name:
REVENUE_BILL
1
REVENUE_CODE
2
BILL_TYPE
3
SVC_BEGIN_DT
4
SVC_END_DT
5
AHCCCS_COVERED
6
THIRD_DIGIT_REQ
7
UNITS_REQ
8
PROCEDURE_CODE_REQ

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type

Data Length Null?

VARCHAR2
VARCHAR2
DATE
DATE
NUMBER
NUMBER
NUMBER

2
1
7
7
9,0
9,2
9,2

N
N
N
Y
Y
Y
Y

VARCHAR2
VARCHAR2
NUMBER
DATE
DATE
VARCHAR2
NUMBER
NUMBER
NUMBER

2
1
3,0
7
7
2
9,0
9,2
9,2

N
N
N
N
Y
Y
Y
Y
Y

VARCHAR2
VARCHAR2

2
50

N
Y

VARCHAR2
NUMBER
VARCHAR2
NUMBER
VARCHAR2
NUMBER
VARCHAR2

2
3,0
1
3,1
9
3,1
5

N
N
Y
Y
Y
Y
Y

VARCHAR2
VARCHAR2
DATE
DATE
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2

3
3
7
7
1
1
1
1

N
N
N
Y
Y
Y
Y
Y

155

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I

Column_Name

9
CHANGE_CONTROL_DATE
10
CHANGE_CONTROL_USERID
11
CHANGE_CONTROL_PGM
12
CIS_ADD_DATE
13
ERROR_CODE
14
PA_CODE
15
MEDICARE_REV_INDICATOR
16
MEDICARE_PROC_INDICATOR
Table Name:
REVENUE_CODE
1
REVENUE_CODE
2
DESCRIPTION
3
ANCILLARY_IND
4
AHCCCS_COVERAGE
5
MIN_AGE
6
MAX_AGE
7
SEX
8
SVC_BEGIN_DT
9
SVC_END_DT
10
CHANGE_CONTROL_DATE
11
CHANGE_CONTROL_USERID
12
CHANGE_CONTROL_PGM
13
CIS_ADD_DATE
Table Name:
RPT_CLIENT_ID_LIST
1
REPORT_REQUEST_ID
2
CLIENT_ID
Table Name:
RPT_REQUEST
1
REPORT_REQUEST_ID
2
REQUESTOR_ID
3
DATE_REPORT_WAS_REQUESTED
4
DATE_TO_RUN_REPORT
5
DATE_REPORT_WAS_RUN
6
JOB_NUMBER
7
JOB_STATUS
8
REPORT_NUMBER
9
REPORT_NO_COPIES
10
REPORT_DATE_START
11
REPORT_DATE_END
12
REPORT_LEVEL

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type

Data Length Null?

DATE
VARCHAR2
VARCHAR2
DATE
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2

7
10
8
7
4
1
1
1

Y
Y
Y
N
Y
Y
Y
Y

VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
NUMBER
NUMBER
VARCHAR2
DATE
DATE
DATE
VARCHAR2
VARCHAR2
DATE

3
30
1
1
3,0
3,0
1
7
7
7
10
8
7

N
Y
Y
Y
Y
Y
Y
N
Y
Y
Y
Y
N

NUMBER
VARCHAR2

10,0
10

N
Y

NUMBER
VARCHAR2
DATE
DATE
DATE
VARCHAR2
VARCHAR2
VARCHAR2
NUMBER
DATE
DATE
NUMBER

10,0
30
7
7
7
5
8
6
1,0
7
7
1,0

N
N
N
Y
Y
Y
Y
N
Y
N
N
N

156

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50

Column_Name
COMBINED_CONTR
COUNTY
CONTR_ID
SUB_CONTR_ID
FACILITY_ID
INTAKE_TYPE
PROG
TREAT
MODALITY
DOB_START
DOB_END
SEX
ETHNICITY
LEGAL_STAT
REFERRAL_SOURCE
AXIS_I_START
AXIS_I_END
ASSESSA_PROB
SUBSTANCE
CMI_STAT_YN
CLIENT_ID
SEH_CHILD_YN
IV_DRUG_USER_YN
PREG_WOMAN_YN
WW_DEP_CHILD_YN
IBM_DEST_ID
BREAK_CONTR_ID
BREAK_SUB_CONTR_ID
BREAK_FACILITY_ID
ASSESSA_INTERVAL_1
ASSESSA_SEQ_1
ASSESSA_INTERVAL_2
ASSESSA_SEQ_2
AHCCCS
BREAK_PROG
BREAK_TREAT
BREAK_TREAT_MODE
REPORT_COMMENT

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type
VARCHAR2
NUMBER
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
DATE
DATE
NUMBER
NUMBER
NUMBER
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
NUMBER
VARCHAR2
NUMBER
NUMBER
NUMBER
NUMBER
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
NUMBER
NUMBER
NUMBER
NUMBER
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2

Data Length Null?
1
2,0
2
2
2
1
2
1
2
7
7
1,0
2,0
2,0
2
6
6
2
4
1,0
10
1,0
1,0
1,0
1,0
4
1
1
1
1,0
2,0
1,0
2,0
5
1
1
1
60

Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

157

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual

Column_I

Column_Name

Table Name:
RPT_VALID_SELECT
1
REPORT_NUMBER
2
REPORT_NO_COPIES
3
REPORT_DATE_START
4
COMBINED_CONTR
5
COUNTY
6
CONTR_ID
7
SUB_CONTR_ID
8
FACILITY_ID
9
INTAKE_TYPE
10
PROG
11
TREAT
12
MODALITY
13
AGE_START
14
SEX
15
ETHNICITY
16
LEGAL_STAT
17
REFERRAL_SOURCE
18
AXIS_I_START
19
ASSESSA_PROB
20
SUBSTANCE
21
CMI_STAT_YN
22
CLIENT_ID
23
SEH_CHILD_YN
24
IV_DRUG_USER_YN
25
PREG_WOMAN_YN
26
WW_DEP_CHILD_YN
27
BREAK_CONTR_ID
28
BREAK_SUB_CONTR_ID
29
BREAK_FACILITY_ID
30
ASSESSA_INTERVAL_1
31
ASSESSA_SEQ_1
32
ASSESSA_INTERVAL_2
33
ASSESSA_SEQ_2
34
AHCCCS
35
BREAK_PROG
36
BREAK_TREAT

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2

Data Length Null?
6
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
1
2
1
1
1

N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

158

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
37

BREAK_TREAT_MODE

Column_I

VARCHAR2

Column_Name

Table Name:
RUN_PARAMETERS
1
RUN_PARAMETER_ID
2
PARAMETER_SEQUENCE_NBR
3
PROCESSING_ORDER
4
JOB_NAME
5
REQUESTOR_ID
6
DATE_REQUEST_WAS_ENTERED
7
DATE_TO_RUN_JOB
8
DATE_JOB_WAS_RUN
9
REQUEST_STATUS
10
NUMBER_OF_COPIES
11
PROCESSING_PERIOD_START
12
PROCESSING_PERIOD_END
13
CONTR_ID
14
SUB_CONTR_ID
15
FACILITY_ID
16
CLIENT_ID
17
CASE_MGR_ID
18
COUNTY_RESIDENCE
19
DOB_START
20
DOB_END
21
SEX
22
RACE
23
LEGAL_STAT
24
REFERRAL
25
SMI_FLAG
26
SED_FLAG
27
IV_DRUG_FLAG
28
PREGNANT_FLAG
29
WOMAN_DEP_FLAG
30
PROGRAM_IND
31
AXIS_I_START
32
AXIS_I_END
33
ASSESSA_PROB
34
SUBSTANCE_START
35
SUBSTANCE_END

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type
NUMBER
NUMBER
NUMBER
VARCHAR2
VARCHAR2
DATE
DATE
DATE
VARCHAR2
NUMBER
DATE
DATE
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
DATE
DATE
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2

1

Y

Data Length Null?
9,0
3,0
3,0
8
8
7
7
7
8
1,0
7
7
2
4
3
10
5
2
7
7
1
2
1
2
1
1
1
1
1
1
6
6
2
4
4

N
N
N
N
N
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

159

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I

Column_Name

36
PROCEDURE_CODE_START
37
PROCEDURE_CODE_END
38
SVC_TYPE
39
AHCCCS_ELIGIBLE
40
MHS_CAT
41
CONTRACT_TYPE
42
CAPITATION_CODE
43
CATEGORY_CODE
44
PROGRAM_CODE
45
COMBINED_RBHA
46
IBM_DEST_ID
47
BREAK_CONTR_ID
48
BREAK_SUB_CONTR_ID
49
BREAK_FACILITY_ID
50
BREAK_CASE_MGR
51
BREAK_SVC_TYPE
52
BREAK_MHS_CAT
53
BREAK_CONTRACT_TYPE
54
REPORT_COMMENT
55
FREE_FORM_PARAMETERS
Table Name:
SERVICE_AUTH
1
PRIOR_AUTH_NBR
2
CLIENT_ID
3
PROCEDURE_CODE
4
EFFECTIVE_DT
5
CANCEL_DT
6
SVC_TYPE
7
PROVIDER_ID
8
CHANGE_SEQ_NBR
9
CASE_MGR_ID
10
FUND_TYPE
11
AUTH_UNITS
12
USED_UNITS
13
AUTH_AMOUNT
14
USED_AMOUNT
15
CONTR_ID
16
SUB_CONTR_ID
17
FACILITY_ID

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type

Data Length Null?

VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2

5
5
1
1
1
1
4
2
1
1
12
1
1
1
1
1
1
1
60
80

Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

VARCHAR2
VARCHAR2
VARCHAR2
DATE
DATE
VARCHAR2
VARCHAR2
NUMBER
VARCHAR2
VARCHAR2
NUMBER
NUMBER
NUMBER
NUMBER
VARCHAR2
VARCHAR2
VARCHAR2

6
10
5
7
7
1
9
4,0
5
2
8,2
8,2
7,2
7,2
2
4
3

N
N
N
N
N
N
N
N
Y
Y
Y
Y
Y
Y
Y
Y
Y

160

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I

Column_Name

18
DIAGNOSIS_CODE
19
EDS_UPDATE_ID
20
EDS_UPDATE_DT
21
EDS_FILE_DT
22
EDS_ADD_DT
23
CIS_ADD_DATE
24
CHANGE_CONTROL_DATE
25
CHANGE_CONTROL_PGM
26
CHANGE_CONTROL_USER_ID
Table Name:
SERVICE_AUTH_DELETE
1
PROVIDER_ID
2
CONTR_ID
3
PRIOR_AUTH_NBR
4
EFFECTIVE_DT
5
CANCEL_DT
6
SVC_TYPE
7
PROCEDURE_CODE
8
SUB_CONTR_ID
9
FACILITY_ID
10
CIS_ADD_DATE
11
ORIG_CIS_ADD_DATE
12
CHANGE_CONTROL_DATE
13
CHANGE_CONTROL_PGM
14
CHANGE_CONTROL_USER_ID
15
CLIENT_ID
Table Name:
STATE_CAPITATION_ROSTER
1
TRANSACTION_NBR
2
STATUS
3
CONTR_ID
4
CLIENT_ID
5
PROGRAM_CODE
6
PAYMENT_FROM_DATE
7
PAYMENT_TO_DATE
8
NUMBER_OF_DAYS_COVERED
9
TRANSACTION_TYPE
10
ADJ_ACTION_CODE
11
ADM_CAP_AMT
12
CASE_MGT_CAP_AMT

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type

Data Length Null?

VARCHAR2
VARCHAR2
DATE
DATE
DATE
DATE
DATE
VARCHAR2
VARCHAR2

6
8
7
7
7
7
7
8
8

Y
Y
Y
Y
Y
Y
Y
Y
Y

VARCHAR2
VARCHAR2
VARCHAR2
DATE
DATE
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
DATE
DATE
DATE
VARCHAR2
VARCHAR2
VARCHAR2

9
2
6
7
7
1
5
4
3
7
7
7
8
8
10

N
N
N
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

NUMBER
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
DATE
DATE
NUMBER
VARCHAR2
VARCHAR2
NUMBER
NUMBER

9,0
2
2
10
1
7
7
4,0
1
2
7,2
7,2

N
N
N
N
Y
Y
Y
Y
Y
Y
Y
Y

161

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I

Column_Name

13
CASE_SERVICE_CAP_AMT
14
NON_CASE_SERVICE_CAP_AMT
15
CONTROL_DATE
16
CONTROL_PROGRAM
17
PROCESS_DATE
18
BUSINESS_MONTH
19
INVOICE_NBR
Table Name:
TMP_AGE4
1
CRN_DATE
2
CRN_BATCH
3
CRN_DOC
4
CRN_LINE_NBR
5
ICN_NBR
6
CONTR_ID
7
ACTION_CD
Table Name:
TMP_AGE4A
1
CRN_KEY
2
ICN_NBR
3
CONTR_ID
Table Name:
TMP_AGE4B
1
CRN_DATE
2
CRN_BATCH
3
CRN_DOC
4
CRN_LINE_NBR
5
ICN_NBR
6
CONTR_ID
7
ERR_CODES
Table Name:
TMP_AGE4C
1
CRN_DATE
2
CRN_BATCH
3
CRN_DOC
4
CRN_LINE_NBR
5
ICN_NBR
6
CONTR_ID
Table Name:
TMP_AGE4D
1
CRN_KEY
2
ERR_CODES

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type

Data Length Null?

NUMBER
NUMBER
DATE
VARCHAR2
DATE
NUMBER
VARCHAR2

7,2
7,2
7
10
7
6,0
9

Y
Y
Y
Y
Y
N
Y

DATE
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR

7
4
3
2
11
2
1

Y
Y
Y
Y
Y
Y
Y

CHAR
CHAR
CHAR

14
11
2

Y
Y
Y

DATE
CHAR
CHAR
CHAR
CHAR
CHAR
CHAR

7
4
3
2
11
2
12

Y
Y
Y
Y
Y
Y
Y

DATE
CHAR
CHAR
CHAR
CHAR
CHAR

7
4
3
2
11
2

Y
Y
Y
Y
Y
Y

CHAR
CHAR

14
12

Y
Y

162

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I

Column_Name

Table Name:
TMP_ELIG
1
AHCCCS_ID
2
CLIENT_ID
3
CONTR_ID
4
START_DT
5
INTAKE_DT
Table Name:
TMP_ELIG2
1
AHCCCS_ID
2
CLIENT_ID
3
CONTR_ID
4
START_DT
5
INTAKE_DT
Table Name:
TMP_H74155_DETAIL
1
CONTR_ID
2
NBR_CHILD_T19
3
NBR_CHILD_NON_T19
4
NBR_CHILD_SUBTOTAL
5
NBR_CHILD_UNDUP
6
NBR_SMI_T19
7
NBR_SMI_NON_T19
8
NBR_SMI_SUBTOTAL
9
NBR_SMI_UNDUP
10
NBR_GMH
11
NBR_GMH_NON_T19
12
NBR_DRUGS
13
NBR_DRUGS_NON_T19
14
NBR_ALCOHOL
15
NBR_ALCOHOL_NON_T19
16
NBR_OTHER_PROGRAMS
17
NBR_NONSMI_SUBTOTAL
18
NBR_NONSMI_UNDUP
19
NBR_UNDUPLICATED
Table Name:
TMP_H74155_HEADER
1
PERIOD_START_DT
2
PERIOD_END_DT
3
RUN_DATE

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type

Data Length Null?

CHAR
CHAR
CHAR
DATE
DATE

9
10
2
7
7

Y
Y
Y
Y
Y

CHAR
CHAR
CHAR
DATE
DATE

9
10
2
7
7

Y
Y
Y
Y
Y

CHAR
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER

2
7,0
7,0
7,0
7,0
7,0
7,0
7,0
7,0
7,0
7,0
7,0
7,0
7,0
7,0
7,0
7,0
7,0
7,0

Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

CHAR
CHAR
CHAR

10
10
10

Y
Y
Y

163

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual

Column_I

Column_Name

Table Name:
TMP_H74155T_DETAIL
1
CONTR_ID
2
NBR_CHILD_T19
3
NBR_CHILD_NON_T19
4
NBR_CHILD_SUBTOTAL
5
NBR_CHILD_UNDUP
6
NBR_SMI_T19
7
NBR_SMI_NON_T19
8
NBR_SMI_SUBTOTAL
9
NBR_SMI_UNDUP
10
NBR_GMH
11
NBR_GMH_NON_T19
12
NBR_DRUGS
13
NBR_DRUGS_NON_T19
14
NBR_ALCOHOL
15
NBR_ALCOHOL_NON_T19
16
NBR_OTHER_PROGRAMS
17
NBR_NONSMI_SUBTOTAL
18
NBR_NONSMI_UNDUP
19
NBR_UNDUPLICATED
Table Name:
TMP_H74155T_HEADER
1
PERIOD_START_DT
2
PERIOD_END_DT
3
RUN_DATE
Table Name:
TMP_H74VAL
1
TBL_ID
2
VVAL_CODE
3
VVAL_DESCRIPTION
Table Name:
TMP_LEVEL3_PROV_TYPE
1
PROCEDURE_CODE
2
PROVIDER_TYPE
3
EFFECTIVE_DATE
4
END_DATE
Table Name:
TMP_LOG139
1
CONTR_ID
2
RBHA_NAME
3
OLD_COUNT

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type

Data Length Null?

CHAR
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER
NUMBER

2
7,0
7,0
7,0
7,0
7,0
7,0
7,0
7,0
7,0
7,0
7,0
7,0
7,0
7,0
7,0
7,0
7,0
7,0

Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y
Y

CHAR
CHAR
CHAR

10
10
10

Y
Y
Y

VARCHAR2
VARCHAR2
VARCHAR2

3
3
30

Y
Y
Y

VARCHAR2
VARCHAR2
DATE
DATE

5
2
7
7

N
N
Y
Y

2
50
7,0

Y
Y
Y

CHAR
CHAR
NUMBER

164

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I

Column_Name

4
TOTAL_COUNT
Table Name:
TMP_PDEL
1
CRN_DATE
2
CRN_BATCH
3
CRN_DOC
4
CRN_LINE_NBR
5
ICN_NBR
6
RBHA_ID
Table Name:
TMP_PDEL2
1
CRN_NBR
2
ICN_NBR
3
RBHA_ID
4
ERROR_CODES
Table Name:
TMP_PEND_CRNKEY
1
CRN_DATE
2
CRN_BATCH
3
CRN_DOC
Table Name:
TMP_UINTK
1
CLIENT_ID
2
INTAKE_DATE
Table Name:
TMP74603X
1
SUB_CONTR_ID
2
FACILITY_ID
3
START_DT
4
END_DT
Table Name:
TMP74611
1
ICN_NBR
2
LINE_NBR
Table Name:
USER_GROUP_XREF
1
USER_ID
2
GROUP_ID
3
GRANT_ACCESS
Table Name:
USER_SETUP
1
USER_ID
2
L_NM
3
M_NM
4
F_NM
5
ADDRESS_1

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type

Data Length Null?

NUMBER

7,0

Y

DATE
CHAR
CHAR
CHAR
CHAR
CHAR

7
4
3
2
11
2

Y
Y
Y
Y
Y
Y

CHAR
CHAR
CHAR
CHAR

14
11
2
12

Y
Y
Y
Y

DATE
NUMBER
NUMBER

7
4,0
3,0

N
N
N

CHAR
DATE

10
7

Y
Y

CHAR
CHAR
DATE
DATE

4
3
7
7

Y
Y
Y
Y

CHAR
NUMBER

11
2,0

Y
Y

VARCHAR2
VARCHAR2
VARCHAR2

30
30
1

N
N
N

VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2

30
15
1
10
30

N
N
Y
N
Y

165

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Column_I

Column_Name

6
ADDRESS_2
7
STATE
8
ZIP
9
DEFAULT_MENU
Table Name:
USER_TABLE_XREF
1
USER_ID
2
TNAME
3
ACCESS_TYPE
Table Name:
VALIDV_LIST_REF
1
TBL_ID
2
TBL_DESCRIPTION
Table Name:
VALIDV_VALS_REF
1
TBL_ID
2
VVAL_CODE
3
VVAL_DESCRIPTION

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

Data Type

Data Length Null?

VARCHAR2
VARCHAR2
VARCHAR2
VARCHAR2

30
2
10
7

Y
Y
Y
Y

VARCHAR2
VARCHAR2
VARCHAR2

30
30
1

N
N
N

VARCHAR2
VARCHAR2

3
30

N
Y

VARCHAR2
VARCHAR2
VARCHAR2

3
3
30

N
N
Y

166

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Appendix E: Request for Restrictions on Use or Disclosure of PHI

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

167

Arizona Department of Health Services
Division of Behavioral Health Services

REQUEST FOR RESTRICTION ON USE OR DISCLOSURE OF
PROTECTED HEALTH INFORMATION
INFORMATION
Date: __________________________________________________
Name: _________________________________________________
Date of birth: ____________________________________________
REQUESTED RESTRICTION
I understand that the Arizona Department of Health Services/Division of Behavioral Health Services (ADHS/DBHS) may use or disclose my Protected Health Information for the purposes of treatment, payment, and health care operations. ADHS/DBHS may also disclose information to someone involved in my care or the payment for my care, such as a family member or friend. I understand that ADHS/DBHS does not have to agree to my request.
I hereby request a restriction on ADHS/DBHS’ use or disclosure of my Protected Health Information.
The information I want limited is:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
I want to limit:
ADHS/DBHS’ use of this information.
ADHS/DBHS’ disclosure of this information.
Both the use and disclosure of this information.
I want the limits to apply to the following person/entity (for example, a spouse):
______________________________________________________________________________________
I understand that ADHS/DBHS does not have to agree to my request.
EXCEPTIONS
Even if ADHS/DBHS agrees to the restriction, ADHS/DBHS may share the information regardless of the restriction in the following circumstances:
During a medical emergency, if the restricted information is needed to provide emergency treatment.
However, if the information is disclosed during an emergency, ADHS/DBHS will tell the recipient not to use or disclose the information for any other purposes.
For certain public health activities.
For reporting abuse, neglect, exploitation, domestic violence or other crimes
ADHS/DBHS
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Version 1.0
April 14, 2003

168

REQUEST FOR RESTRICTION ON USE OR DISCLOSURE OF
PROTECTED HEALTH INFORMATION – Page 2
For health agency oversight activities or law enforcement investigations.
For judicial or administrative proceedings.
For identifying decedents to coroner and medical examiners or determining a cause of death.
For organ procurement.
For certain research activities.
For workers’ compensation programs.
For uses or disclosures otherwise required by law.
TERMINATION
If a restriction is agreed to, it may be terminated if:
1.

I request, or agree to, the termination in writing.

2.

I orally agree to the termination and the oral agreement is documented.

3.

ADHS/DBHS informs me that it is terminating the agreement. In this case, the termination is effective for
Protected Health Information created by ADHS/DBHS or received by ADHS/DBHS after I am notified of the termination. YOUR RIGHTS
For more information about your privacy rights, see the “Notice of Privacy Practices” available on our website at www.hs.state.az.us/bhs/index.htm or by sending a written request.
If you believe your privacy rights as set forth in this Notice have been violated, and you wish to complain, please write or contact one of the offices listed below:
Prior to July 1, 2003
Arizona Department of Health Services
Division of Behavioral Health Services
Manager for Grievance and Appeals
2122 East Highland Avenue, Suite 100
Phoenix Arizona 85016
Phone: [phone]

On or After July 1, 2003
Arizona Department of Health Services
Division of Behavioral Health Services
Manager for Grievance and Appeals
150 N. 18th Avenue
Phoenix Arizona 85007
Phone: [phone]

We will take no retaliatory action against you if you make such complaints.
SIGNATURE
Date: ______________________________________
Signature: _________________________________________________________
Enrolled person/Representative/Guardian
If signed by someone other than the Enrolled person, state your relationship to the enrolled person:
__________________________________________________________________
Witness: ___________________________________________________________

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

169

Arizona Department of Health Services
Division of Behavioral Health Services
RESPONSE TO REQUEST FOR RESTRICTION ON USE OR
DISCLOSURE OF PROTECTED HEALTH INFORMATION
Date:

__________________________________

Name:

__________________________________

Address:

__________________________________
__________________________________

Dear _____________________:
On _______________, you requested that the Arizona Department of Health Services/Division of Behavioral Health
Services (ADHS/DBHS) limit its use or disclosure of your Protected Health Information.
ADHS/DBHS agrees to the restriction you requested.
ADHS/DBHS does not agree to the restriction you requested.
Other _______________________________________________________________________
Even if a restriction is agreed to, the information may be shared regardless in the following circumstances:
During a medical emergency, if the restricted information is needed to provide emergency treatment. However, if the information is disclosed during an emergency, ADHS/DBHS will tell the recipient not to use or disclose the information for any other purposes.
For certain public health activities.
For reporting abuse, neglect, exploitation, domestic violence or other crimes.
For health agency oversight activities or law enforcement investigations.
For judicial or administrative proceedings.
For identifying decedents to coroner and medical examiners or determining a cause of death.
If a restriction is agreed to, it may be terminated if:
You request, or agree to, the termination in writing.
You orally agree to the termination and the oral agreement is documented.
ADHS/DBHS informs you that it is terminating the agreement. In this case, the termination is only effective for
Protected Health Information created by ADHS/DBHS or received by ADHS/DBHS after you are notified of the termination. For more information about your privacy rights, see the “Notice of Privacy Practices” available on our website at www.hs.state.az.us/bhs/index.htm or by sending a written request.
If you believe your privacy rights as set forth in this Notice have been violated, and you wish to complain, please write or contact one of the offices listed below:

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

170

Prior to July 1, 2003
Arizona Department of Health Services
Division of Behavioral Health Services
Manager for Grievance and Appeals
2122 East Highland Avenue, Suite 100
Phoenix Arizona 85016
Phone: [phone]

On or After July 1, 2003
Arizona Department of Health Services
Division of Behavioral Health Services
Manager for Grievance and Appeals
150 N. 18th Avenue
Phoenix Arizona 85007
Phone: [phone]

We will take no retaliatory action against you if you make such complaints.

Sincerely,

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

171

Arizona Department of Health Services
Division of Behavioral Health Services

TERMINATION OF RESTRICTION ON USE OR DISCLOSURE OF
PROTECTED HEALTH INFORMATION
Date: ________________________________________________
Name: _______________________________________________
Date of birth: __________________________________________

The enrolled person named above requested a restriction on the use or disclosure of Protected Health Information by the Arizona Department of Health Services/Division of Behavioral Health Services, (ADHS/DBHS) on
____________________ (insert date).
The enrolled person hereby requests that the restriction be terminated.
Signature of enrolled person or representative: _______________________________________________
If representative, give relationship: ___________________________________________________
The enrolled person hereby agrees to the termination of the restriction.
Signature of enrolled person or representative: _______________________________________________
If representative, give relationship: ___________________________________________________
The enrolled person orally agreed to the termination.
Signature of ADHS/DBHS representative who witnessed the oral agreement:
__________________________________________________
ADHS/DBHS is hereby informing you that the agreement is terminated. The termination is effective only with respect to Protected Health Information created or received by ADHS/DBHS after you have received this notification.
Signature of ADHS/DBHS representative:
__________________________________________________________
YOUR RIGHTS
For more information about your privacy rights, see the “Notice of Privacy Practices” available on our website at www.hs.state.az.us/bhs/index.htm or by sending a written request.
If you believe your privacy rights as set forth in this Notice have been violated, and you wish to complain, please write or contact one of the offices listed below:

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

172

Prior to July 1, 2003
Arizona Department of Health Services
Division of Behavioral Health Services
Manager for Grievance and Appeals
2122 East Highland Avenue, Suite 100
Phoenix Arizona 85016
Phone: [phone]

On or After July 1, 2003
Arizona Department of Health Services
Division of Behavioral Health Services
Manager for Grievance and Appeals
150 N. 18th Avenue
Phoenix Arizona 85007
Phone: [phone]

We will take no retaliatory action against you if you make such complaints.

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

173

Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Appendix F: Request For Confidential Communications

ADHS/DBHS
HIPAA Privacy Manual
Version 1.0
April 14, 2003

174

Arizona Department of Health Services
Division of Behavioral Health Services

REQUEST FOR CONFIDENTIAL COMMUNICATIONS
Date: ______________________________________________
Name: _____________________________________________
Date of birth: ________________________________________
ALTERNTIVE CONTACT INFORMATION
You may request to receive confidential communications of Protected Health Information by alternative means or at alternative addresses.
You must indicate to us that the disclosures of all or part of the information would endanger you. We will accommodate all reasonable requests.
If you make a request for confidential communications, you must give us an alternative address or other method of contacting you (phone number, email address, etc.). Please specify how or where you wish to be contacted:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Signature of enrolled person or representative: ______________________________________________________
If representative, give relationship: __________________________________________________________
YOUR RIGHTS
For more information about your privacy rights, see the “Notice of Privacy Practices” available on our website at www.hs.state.az.us/bhs/index.htm or by sending a written request.
If you believe your privacy rights as set forth in this Notice have been violated, and you wish to complain, please write or contact one of the offices listed below:
Prior to July 1, 2003
Arizona Department of Health Services
Division of Behavioral Health Services
Manager for Grievance and Appeals
2122 East Highland Avenue, Suite 100
Phoenix Arizona 85016
Phone: [phone]

On or After July 1, 2003
Arizona Department of Health Services
Division of Behavioral Health Services
Manager for Grievance and Appeals
150 N. 18th Avenue
Phoenix Arizona 85007
Phone: [phone]

We will take no retaliatory action against you if you make such complaints.

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Arizona Department of Health Services
Division of Behavioral Health Services

RESPONSE TO REQUEST FOR CONFIDENTIAL
COMMUNICATIONS
Date:

_____________________

Address:

______________________________________
______________________________________
______________________________________

Dear ________________:
The Arizona Department of Health Services/Division of Behavioral Health Services (ADHS/DBHS) received your request for confidential communications dated _____________________________. ADHS/DBHS has determined the following in response to your request:
You have indicated that confidential communications are required because you would otherwise be endangered. You have provided an alternative means of communication and ADHS/DBHS will honor your request to be contacted as you indicated.
You failed to indicate the need for confidential communication is required because you would otherwise be endangered. Please communicate this concern in writing with your request for confidential communications.
You failed to provide an alternative means for ADHS/DBHS to contact you. Please indicate in writing how you want ADHS/DBHS to provide confidential communications.
For more information about your privacy rights, see the “Notice of Privacy Practices” available on our website at www.hs.state.az.us/bhs/index.htm or by sending a written request.
If you believe your privacy rights as set forth in this Notice have been violated, and you wish to complain, please write or contact one of the offices listed below:
Prior to July 1, 2003
Arizona Department of Health Services
Division of Behavioral Health Services
Manager for Grievance and Appeals
2122 East Highland Avenue, Suite 100
Phoenix Arizona 85016
Phone: [phone]

On or After July 1, 2003
Arizona Department of Health Services
Division of Behavioral Health Services
Manager for Grievance and Appeals
150 N. 18th Avenue
Phoenix Arizona 85007
Phone: [phone]

We will take no retaliatory action against you if you make such complaints.
Sincerely,

ADHS/DBHS
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Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Appendix G: Request To Amend Protected Health Information

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Arizona Department of Health Services
Division of Behavioral Health Services

REQUEST TO AMEND PROTECTED HEALTH INFORMATION

Date: ______________________________________
Name: _____________________________________
Date of birth: ________________________________
INFORMATION TO BE CHANGED
Please tell us what information you want changed:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
Please tell us why you want this change. You must give a reason:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
OUR RESPONSIBILITY
We must tell you within 60 days if we will change your Protected Health Information as you requested, or tell you that we need more time (up to 30 additional days) to decide.
Please tell us where to send you this information:
_______________________________________
_______________________________________

Please provide a phone number where we may reach you: _____________________

_______________________________________
If we decide to change the Protected Health Information as you requested, we will send the change to any person who received the information before it was changed. Please tell us if there are any such persons who need the information:
No. There is no other person I know who needs this information.
Yes. Please list the persons’ name and addresses:
________________________________

___________________________________

________________________________

___________________________________

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REQUEST TO AMEND PROTECTED HEALTH INFORMATION –
Page 2
We will also send the amendment to other persons that we know received the information before it was amended if they relied, or might in the future rely, on the information to your detriment (harm). Do you agree with this?
No.
Yes.
We do not have to change the information if:
1.

We did not create the information, unless the person who created the information is unavailable to act on your request to change it (for example, the doctor who originally created the information has died). If this exception applies to you, please explain:

______________________________________________________________________________________
______________________________________________________________________________________
2.

The information is accurate and complete.

3.

You do not have the legal right to access the Protected Health Information you want changed.

4.

The Protected Health Information you want changed is not part of the designated record set. This includes your medical records, billing records and records containing your Protected Health Information that are used by us to make decisions about you.

For more information about your privacy rights, see the “Notice of Privacy Practices” available on our website at www.hs.state.az.us/bhs/index.htm or by sending a written request.
If you believe your privacy rights as set forth in this Notice have been violated, and you wish to complain, please write or contact one of the offices listed below:
Prior to July 1, 2003
Arizona Department of Health Services
Division of Behavioral Health Services
Manager for Grievance and Appeals
2122 East Highland Avenue, Suite 100
Phoenix Arizona 85016
Phone: [phone]

On or After July 1, 2003
Arizona Department of Health Services
Division of Behavioral Health Services
Manager for Grievance and Appeals
150 N. 18th Avenue
Phoenix Arizona 85007
Phone: [phone]

We will take no retaliatory action against you if you make such complaints.
SIGNATURE
Date: _____________________________________________________________
Signature: _________________________________________________________
Enrolled person/Representative/Guardian
If signed by someone other that the Enrolled person, state your relationship to the enrolled person:
__________________________________________________________________
Witness: ___________________________________________________________

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Arizona Department of Health Services
Division of Behavioral Health Services

RESPONSE TO REQUEST TO AMEND
PROTECTED HEALTH INFORMATION

Date:

___________________

Address:

__________________________________
__________________________________
______________________________________

Dear ____________________:
We received your request to amend (change) your Protected Health Information.
We need more time to process your request. We will send you a response to your request by ___________
[insert date].
We will make the change as you requested and will notify the persons you designated of the change.
We will make the change that you requested, but only in part, and will notify the persons you designated of the change. The part of the change that we will make is:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
The part of the change we will not make is:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
See the box checked below for the reason we will not make part of the change you requested.
We will not make the change you requested because:
You did not include a reason to support your request.
The information we have is accurate and complete.
We did not create the information you want changed, and you did not give us a reasonable basis to believe that the originator of the information is no longer available to act on your request to change the information.
The information you want changed is not information that you have a right to access.

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RESPONSE TO REQUEST TO AMEND
PROTECTED HEALTH INFORMATION – Page 2
The information you want changed is not part of the designated record set. This means your medical, billing, payment, claims adjudication or enrollment records containing your Protected Health Information that are used by us to make decisions about you.
Other _______________________________________________________________________________
If we denied your request to change your Protected Health Information, in whole or in part, you may submit a
“Statement of Disagreement.” If you do not submit a “Statement of Disagreement” you may ask us to include your amendment (change) request and our denial along with all future disclosures of the information that you want changed.
If you want to submit a “Statement of Disagreement”, please request and complete our form for that purpose and send or bring it to ADHS/DBHS at the address below.
If you want us to include your amendment (change) request and our denial along with future disclosures of the information that you wanted changed, please send a letter or bring it to the address below.
For more information about your privacy rights, see the “Notice of Privacy Practices” available on our website at www.hs.state.az.us/bhs/index.htm or by sending a written request.
If you believe your privacy rights as set forth in this Notice have been violated, and you wish to complain, please write or contact one of the offices listed below:
Prior to July 1, 2003
Arizona Department of Health Services
Division of Behavioral Health Services
Manager for Grievance and Appeals
2122 East Highland Avenue, Suite 100
Phoenix Arizona 85016
Phone: [phone]

On or After July 1, 2003
Arizona Department of Health Services
Division of Behavioral Health Services
Manager for Grievance and Appeals
150 N. 18th Avenue
Phoenix Arizona 85007
Phone: [phone]

We will take no retaliatory action against you if you make such complaints.
Sincerely,

ADHS/DBHS
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Arizona Department of Health Services
Division of Behavioral Health Services

NOTIFICATION OF AMENDMENT TO
PROTECTED HEALTH INFORMATION
Date:

_____________________

Address:

__________________________________
__________________________________
______________________________________

Dear ________________________:
Name of enrolled person: ____________________________________________________
Date of birth: ________________________________________________________
The enrolled person named above requested an amendment to his or her Protected Health Information. We granted this request, in whole or in part, as follows:
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
You must amend the Protected Health Information in designated record sets by appending or otherwise providing a link from the Protected Health Information to the location of the amendment.
If you have any questions, please call the HIPAA Analyst at [phone].
Sincerely,

ADHS/DBHS
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Arizona Department of Health Services
Division of Behavioral Health Services
STATEMENT OF DISAGREEMENT/REQUEST TO INCLUDE
AMENDMENT REQUEST AND DENIAL WITH FUTURE
DISCLOSURES
Date: ________________________________________
Name: _______________________________________
Date of birth: __________________________________
Address: _____________________________________
Phone: _______________________________________

I understand that the ADHS/DBHS denied my request to change my Protected Health Information. My request was dated ________________.
Mark only one box below:
I want to file this “Statement of Disagreement”. I disagree with the denial because:
(Limiting the length of statement is permitted, but it should be indicated here if you want to do that.)
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
I understand that ADHS/DBHS may prepare a written rebuttal to my Statement of Disagreement. A rebuttal is a statement of why ADHS/DBHS believes my Statement of Disagreement is wrong. If ADHS/DBHS prepares a written rebuttal, I will receive a copy.
I do not want to file a “Statement of Disagreement”, but I want ADHS/DBHS to include my amendment
(change) request and the denial along with all future disclosures of the information subject to my amendment request. YOUR RIGHTS
For more information about your privacy rights, see the “Notice of Privacy Practices” available on our website at www.hs.state.az.us/bhs/index.htm or by sending a written request.
If you believe your privacy rights as set forth in this Notice have been violated, and you wish to complain, please write or contact one of the offices listed below:
Prior to July 1, 2003
Arizona Department of Health Services
Division of Behavioral Health Services
Manager for Grievance and Appeals
2122 East Highland Avenue, Suite 100
Phoenix Arizona 85016
Phone: [phone]

On or After July 1, 2003
Arizona Department of Health Services
Division of Behavioral Health Services
Manager for Grievance and Appeals
150 N. 18th Avenue
Phoenix Arizona 85007
Phone: [phone]

We will take no retaliatory action against you if you make such complaints.

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SIGNATURE
Date: ______________________________________
Signature: _________________________________________________________
Enrolled person/Representative/Guardian
If signed by someone other than the Enrolled person, state your relationship to the enrolled person:
__________________________________________________________________

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Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Appendix H: Complaint Regarding Violation of Privacy of Protected Health
Information Form

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Arizona Department of Health Services
Division of Behavioral Health Services

COMPLAINT REGARDING VIOLATION OF PRIVACY OF
PROTECTED HEALTH INFORMATION
ENROLLED PERSON INFORMATION
Date: _________________________________________________
Name: ________________________________________________
Date of birth: ___________________________________________
COMPLAINT
I am filing this Complaint because I believe that the privacy rights of the above named enrolled person have been violated. I understand that the Arizona Department of Health Services/Division of Behavioral Health Services
(ADHS/DBHS) will investigate this complaint and notify me of its decision in writing.
I believe the enrolled person’s privacy rights were violated by ADHS/DBHS as a result of the following (state actions you believe violated your privacy rights):
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
(attach additional sheets as necessary)
CONTACT INFORMATION
Please provide the following information, which will allow ADHS/DBHS to contact you if we need further information about your complaint.
Name of party filing the Complaint: _____________________________________________________
Relationship to the enrolled person:
Self
Other
___________________________________________________________________
(state the nature of your relationship to the enrolled person)
Address: __________________________________________________________________________
Telephone: ________________________________________________________________________

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COMPLAINT REGARDING VIOLATION OF PRIVACY OF
PROTECTED HEALTH INFORMATION – Page 2
YOUR RIGHTS
For more information about your privacy rights, see the “Notice of Privacy Practices” available on our website at www.hs.state.az.us/bhs/index.htm or by sending a written request.
If you believe your privacy rights as set forth in this Notice have been violated, and you wish to complain, please write or contact one of the offices listed below:
Prior to July 1, 2003
Arizona Department of Health Services
Division of Behavioral Health Services
Manager for Grievance and Appeals
2122 East Highland Avenue, Suite 100
Phoenix Arizona 85016
Phone: [phone]

On or After July 1, 2003
Arizona Department of Health Services
Division of Behavioral Health Services
Manager for Grievance and Appeals
150 N. 18th Avenue
Phoenix Arizona 85007
Phone: [phone]

We will take no retaliatory action against you if you make such complaints.
SIGNATURE
Date: ______________________________________
Signature: _________________________________________________________
Enrolled person/Representative/Guardian
If signed by someone other that the Enrolled person, state your relationship to the enrolled person:
__________________________________________________________________
Witness: ___________________________________________________________

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Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Appendix I: Authorization for Use or Disclosure of Protected Health
Information

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Arizona Department of Health Services
Division of Behavioral Health Services
AUTHORIZATION FOR USE OR DISCLOSURE
OF PROTECTED HEALTH INFORMATION
Completion of this document authorizes the disclosures and/or use of individually identifiable health information, as set forth below, consistent with Arizona and Federal law concerning the privacy of such information. Failure to provide all information requested will invalidate this Authorization.

USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
I hereby authorize the use and disclosure of my Protected Health Information as follows:
Enrolled person Name:__________________________________________________________________
Persons/Organizations authorized to use or disclose the information: ______________________________
_____________________________________________________________________________________
Persons/Organizations authorized to receive the information: _____________________________________
(name, address, telephone number)

______________________________________________________________________________________
Purpose of the use or disclosure: ___________________________________________________________
This Authorization applies to the following information (select only one of the following):1
All health information pertaining to my medical history, mental or physical condition and treatment received.
[Optional] Except: ___________________________________________________________________
Only the following records or types of information (including any dates): ________________________
______________________________________________________________________________________
EXPIRATION
This Authorization expires (insert date or event): _______________________________________________
RESTRICTIONS
This Authorization may not be used to release Substance Abuse or Confidential Communicable Disease/HIV information in combination with any other health care information. Federal law requires a specific Authorization be used for the disclosure of this information.
Protected Health Information that is disclosed pursuant to this Authorization remains privileged. The recipient of this information may not redisclose this information without the written authorization of the enrolled person or the enrolled person’s health care decision maker, unless otherwise provided by law. [ARS §12-2294(F)].
YOUR RIGHTS
1

This form may not be used to release psychotherapy notes in combination with other types of health information (45
CFR §164.508(b)(ii). If this form is being used to authorize the release of psychotherapy notes, a separate form must be used to authorize release of any other Protected Health Information.
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AUTHORIZATION FOR USE OR DISCLOSURE
OF PROTECTED HEALTH INFORMATION – Page 2
I understand that I may refuse to sign this Authorization. My refusal to sign will not affect my ability to obtain treatment or payment or my eligibility for benefits. I may inspect or copy any used or disclosed under this
Authorization, unless the information is contraindicated as determined by my psychiatrist.
I may revoke this Authorization at any time. My revocation must be writing, signed by me or on my behalf. My revocation will be effective upon receipt, but will not be effective to the extent that the Requesting Party or others have acted in reliance upon this Authorization.
I have a right to receive a copy of this Authorization.
SIGNATURE
Date: ______________________________________

Time: ________________________ AM/PM

Signature: _________________________________________________________
Enrolled person/Representative/Guardian
If signed by someone other than the Enrolled person, state your relationship to the enrolled person:
__________________________________________________________________

Witness: ___________________________________________________________

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Arizona Department of Health Services
Division of Behavioral Health Services
AUTHORIZATION FOR DISCLOSURE OF
SUBSTANCE ABUSE OR CONFIDENTIAL COMMUNICABLE
DISEASE/HIV INFORMATION
NOTE: Where information accompanies this disclosure form, this information has been disclosed to you from records protected by Federal Confidentiality of Alcohol or Drug Abuse Patient Records rules (42 CFR Part 2) or Arizona State
Statutes (§36-664). Generally, the Arizona Department of Health Services/Division of Behavioral Health Services
(ADHS/DBHS) may not disclose to a person outside of ADHS/DBHS any information regarding substance abuse or
Confidential Communicable Disease/HIV, unless the enrolled person authorizes the disclosure in writing, the disclosure is required by a court order, or the disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation. Federal law restricts any use of substance abuse information to criminally investigate or prosecute a enrolled person.
FEDERAL AND STATE LAW PROHIBIT ANY FURTHER DISCLOSURE OF SUBSTANCE ABUSE OR
CONFIDENTIAL COMMUNICABLE DISEASE/HIV INFORMATION UNLESS FURTHER DISCLOSURE IS
EXPRESSLY PERMITTED BY THE WRITTEN AUTHORIZATION OF THE ENROLLED PERSON TO WHOM
IT PERTAINS OR AS OTHERWISE PERMITTED.

USE AND DISCLOSURE OF SUBSTANCE ABUSE OR CONFIDENTIAL COMMUNICABLE
DISEASE/HIV INFORMATION
I hereby authorize the use and disclosure of my Protected Health Information as follows:
Enrolled person Name:

_______________________________________________________________________

Persons/Organizations authorized to use or disclose the information: ______________________________
_____________________________________________________________________________________
Persons/Organizations authorized to receive the information: _____________________________________
(name, address, telephone number)

______________________________________________________________________________________
This Authorization applies to the following information (select only one of the following):2
All SUBSTANCE ABUSE health information pertaining to my medical history, mental or physical condition and treatment received.
[Optional] Except: ____________________________________________________________________
All CONFIDENTIAL COMMUNICABLE DISEASE/HIV health information pertaining to my medical history, mental or physical condition and treatment received.
[Optional] Except: ____________________________________________________________________
Only the following records or types of information (including any dates): _________________________
______________________________________________________________________________________

2

This form may not be used to release psychotherapy notes in combination with other types of health information (45
CFR §164.508(b)(ii). If this form is being used to authorize the release of psychotherapy notes, a separate form must be used to authorize release of any other Protected Health Information.
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AUTHORIZATION FOR DISCLOSURE OF
SUBSTANCE ABUSE OR CONFIDENTIAL COMMUNICABLE
DISEASE/HIV INFORMATION – Page 2
The purpose for this disclosure is: __________________________________________________________
______________________________________________________________________________________
EXPIRATION
This Authorization expires (insert date or event): _______________________________________________
YOUR RIGHTS
I understand that I may refuse to sign this Authorization. My refusal to sign will not affect my ability to obtain treatment or payment or my eligibility for benefits. I may inspect or copy any used or disclosed under this
Authorization, unless the information is contraindicated as determined by my psychiatrist.
I may revoke this Authorization at any time. My revocation must be writing, signed by me or on my behalf. My revocation will be effective upon receipt, but will not be effective to the extent that the Requesting Party or others have acted in reliance upon this Authorization.
I have a right to receive a copy of this Authorization.
SIGNATURE
Date: ______________________________________

Time: ________________________ AM/PM

Signature: _________________________________________________________
Enrolled person/Representative/Guardian
If signed by someone other than the Enrolled person, state your relationship to the enrolled person:
__________________________________________________________________
Witness: ___________________________________________________________

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Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Appendix J: Accounting of Disclosures

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Arizona Department of Health Services
Division of Behavioral Health Services
REQUEST FOR AN ACCOUNTING OF DISCLOSURES
Date: ____________________________________________
Name: ___________________________________________
Date of Birth: ______________________________________
I would like an accounting of how my Protected Health Information was disclosed by the Arizona Department of
Health Services/Division of Behavioral Health Services (ADHS/DBHS) as required by federal regulations. I understand that ADHS/DBHS does not have to tell me about the following types of disclosures:
1.

Disclosures for purposes of treatment, payment and health care operations.

2.

Disclosures to me.

3.

Disclosures for compliance investigations by the Department of Health and Human Services or the Arizona Health
Care Cost Containment System or other entities authorized by law.

4.

Disclosures incident to an otherwise permitted or required disclosure.

5.

Disclosures pursuant to an authorization.

6.

Disclosures for national security or intelligence purposes,

7.

Disclosures to correctional institutions or law enforcement officials.

8.

Disclosures made prior to April 14, 2003.

I also understand that my right to an accounting of some or all disclosures may be suspended by the government under limited circumstances.
TIME PERIOD AND FORM
I want an accounting of disclosures that covers the following time period:
______________________________________________________________________________________
(Note: The time period must be no longer that six years and may not include dates before April 14, 2003.)

I want the accounting of disclosures in the following form:
On paper
Electronically
Please send my accounting to following address (provide an e-mail address if you request your accounting electronically): ________________________________________________________.
I want to pick up my accounting. Please call me at the following number when it is ready:
____________________________________.

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REQUEST FOR AN ACCOUNTING OF DISCLOSURES – Page 2
EXTENSIONS AND FEES
I understand that ADHS/DBHS must give me the accounting of disclosures within 60 days, or tell me that it needs an extra 30 days (or less) to prepare it.
I understand that I am entitled to one free accounting of disclosures in any 12-month period. Additional accountings will cost $ ________ each.
YOUR RIGHTS
For more information about your privacy rights, see the “Notice of Privacy Practices” available on our website at www.hs.state.az.us/bhs/index.htm or by sending a written request.
If you believe your privacy rights as set forth in this Notice have been violated, and you wish to complain, please write or contact one of the offices listed below:
Prior to July 1, 2003
Arizona Department of Health Services
Division of Behavioral Health Services
Manager for Grievance and Appeals
2122 East Highland Avenue, Suite 100
Phoenix Arizona 85016
Phone: [phone]

On or After July 1, 2003
Arizona Department of Health Services
Division of Behavioral Health Services
Manager for Grievance and Appeals
150 N. 18th Avenue
Phoenix Arizona 85007
Phone: [phone]

We will take no retaliatory action against you if you make such complaints.
SIGNATURE
Date: ______________________________________

Time: ________________________ AM/PM

Signature: _________________________________________________________
Enrolled person/Representative/Guardian
If signed by someone other than the Enrolled person, state your relationship to the enrolled person:
__________________________________________________________________

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Arizona Department of Health Services
Division of Behavioral Health Services

RESPONSE TO REQUEST FOR ACCOUNTING OF DISCLOSURES

Date:

_____________________

Address:

____________________________________
____________________________________
____________________________________

RE:

Request for Accounting of Disclosures

Dear _____________________________:
We received your request for an accounting of disclosures dated _______________.
We need more time to process your request. We will send you an accounting of disclosures by
___________________ [insert date].
You did not provide all the information we needed on your form. Please complete the highlighted areas on the attached form and return it to us.
You have already received one free accounting of disclosures within the last 12 months. Additional accountings cost $ ________. Please send a check for this amount, made payable to ADHS/DBHS or bring it to the address below.
Other __________________________________________________________________________
For more information about your privacy rights, see the “Notice of Privacy Practices” available on our website at www.hs.state.az.us/bhs/index.htm or by sending a written request.
If you believe your privacy rights as set forth in this Notice have been violated, and you wish to complain, please write or contact one of the offices listed below:
Prior to July 1, 2003
Arizona Department of Health Services
Division of Behavioral Health Services
Manager for Grievance and Appeals
2122 East Highland Avenue, Suite 100
Phoenix Arizona 85016
Phone: [phone]

On or After July 1, 2003
Arizona Department of Health Services
Division of Behavioral Health Services
Manager for Grievance and Appeals
150 N. 18th Avenue
Phoenix Arizona 85007
Phone: [phone]

We will take no retaliatory action against you if you make such complaints.
Sincerely,

ADHS/DBHS
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Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Appendix K: Record of Disclosures for Purposes of Public Responsibility

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Arizona Department of Health Services
Division of Behavioral Health Services

RECORD OF DISCLOSURE FOR PURPOSES OF
PUBLIC RESPONSIBILITY
Completion of this document memorializes that the Arizona Department of Health Services/Division of Behavioral
Health Services, (ADHS/DBHS) was permitted or required by law to disclose Protected Health Information for as part of its public responsibility duties, as set forth below, and consistent with Federal regulations (45 CFR Part 160 and 164) and Arizona Revised Statutes:
Name: ____________________________________________
Date: _____________________________________________
Date of Birth: _______________________________________

DISCLOSURE OF PROTECTED HEALTH INFORMATION
This disclosure was made by ADHS/DBHS to the following persons/organizations:
_____________________________________________________________________________________
_____________________________________________________________________________________.
(name, address and telephone number)

The verification of identity and authority of the recipient of this disclosure was confirmed by the following:
____________________________________________________________________________________ .
This disclosure was made on the following date: _______________________________________________.
This disclosure was made by:
(name of ADHS/DBHS workforce member)

REASON FOR DISCLOSURE
This disclosure of information was (select only one of the following):
Victim of abuse, neglect, exploitation, or domestic violence
Judicial or administrative proceeding
Law enforcement
Avert a serious threat to health or safety
Public health activities

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RECORD OF DISCLOSURE FOR PURPOSES OF
PUBLIC RESPONSIBILITY – Page 2
REASON FOR DISCLOSURE Continued
Health oversight activities
Coroner or medical examiner
FDA
Specialized government function
Reporting unlawful activity to an attorney or health oversight agency
NOTIFICATION
Notice of this disclosure

was

was not provided to the enrolled person.

The enrolled person was notified of this disclosure on: _______________________________________________.
The enrolled person was notified by the following: ___________________________________________________.
(name of ADHS/DBHS workforce member)

The enrolled person was not notified due to the following circumstances: __________________________________
_____________________________________________________________________________________ .
SIGNATURE
Date: _____________________________________________________________
Signature: _________________________________________________________
(name of ADHS/DBHS workforce member completing this form)

Title: _____________________________________________________________

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Arizona Department of Health Services
Division of Behavioral Health Services HIPAA Privacy Manual
Appendix L: Arizona Behavioral Health Preemption Guide

CURRENTLY UNDER REVISION

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