INSTRUCTIONS: ARIZONA UNPAID COPAYMENT WORKSHEET (Form CCA-1021A)

When an insurance company is unsuccessful in obtaining co-payment from the parent of a child which has received treatment in Arizona, they may file a form notifying the child care specialist. This document CCA-1021A can be obtained from the website maintained by the Arizona Department of Economic Security.

Arizona Unpaid Copayment Worksheet CCA-1021A Step 1: In the first blank box, enter the name of the child care specialist who provided treatment.

Arizona Unpaid Copayment Worksheet CCA-1021A Step 2: In the second blank box, enter the fax number of the child care specialist, including the area code.

Arizona Unpaid Copayment Worksheet CCA-1021A Step 3: In the third blank box, enter the provider's name.

Arizona Unpaid Copayment Worksheet CCA-1021A Step 4: In the fourth blank box, enter the provider's policy number.

Arizona Unpaid Copayment Worksheet CCA-1021A Step 5: In the fifth blank box, enter the name of a provider contact person.

Arizona Unpaid Copayment Worksheet CCA-1021A Step 6: In the sixth blank box, enter a provider contact phone number, including the area code.

Arizona Unpaid Copayment Worksheet CCA-1021A Step 7: In the seventh blank box, enter the name of the parent or person responsible for the child.

Arizona Unpaid Copayment Worksheet CCA-1021A Step 8: In the eighth blank box, enter the parent or responsible person's ID number.

Arizona Unpaid Copayment Worksheet CCA-1021A Step 9: In the ninth blank box, enter the names of all children concerned.

Arizona Unpaid Copayment Worksheet CCA-1021A Step 10: On the first blank line, enter the beginning date of the time period for which payment is being sought.

Arizona Unpaid Copayment Worksheet CCA-1021A Step 11: On the second blank line, enter the ending date of the time period for which payment is being sought.

Arizona Unpaid Copayment Worksheet CCA-1021A Step 12: On the third blank line, enter the total additional charges owed.

Arizona Unpaid Copayment Worksheet CCA-1021A Step 13: On the fourth blank line, enter the balance of the outstanding copayment owed.

Arizona Unpaid Copayment Worksheet CCA-1021A Step 14: Indicate with a check mark whether attempts have been made to obtain the outstanding copayment orally, in written form, through small claims court, or through other means. If the latter, specify.

Arizona Unpaid Copayment Worksheet CCA-1021A Step 15: The contact person should sign and date the form.