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Arizona LCR-1040A Physician Statement, DDD Home License

People applying to license a child or adult developmental home with Arizona's Division of Developmental Disabilities complete this two-page form. The applicant discloses their health history on page 1, and a physician states on page 2 whether the applicant is physically and mentally able to care for persons with developmental disabilities. The form goes in with the license application.

Who completes it

The applicant completes the health self-disclosure on page 1. The examining physician or licensed provider completes and signs the Physician Statement on page 2.

Submitting and payment

How to submit it
The applicant submits the completed form with the developmental home license application to the licensing agency or the DES Office of Licensing, Certification and Regulation.

Good to know

  • The form must be dated within six months of the date the license application is submitted, so an older physician statement cannot be reused.
  • It applies to both child and adult developmental (foster) homes licensed through the Division of Developmental Disabilities.
  • A Spanish edition, LCR-1040A-S, is published alongside the English form in the DES Documents Center.
  • The current version carries the header LCR-1040A FORFF (1-18) and is a two-page fillable PDF.

Get the official form

Download the current version from the source each time; forms change without notice.

Health Self-Disclosure and Physician Statement

Official pagePDFVersión en español

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

How recent does the Arizona LCR-1040A physician statement need to be?

It must be dated within six months of the submission date of the developmental home license application. If the application is filed after that six-month window closes, a new, more recent physician statement is needed.

Is the LCR-1040A available in Spanish?

Yes. DES lists a Spanish edition, LCR-1040A-S, alongside the English LCR-1040A in its Documents Center. The applicant submits whichever completed version they use with the developmental home license application, and the six-month dating rule still applies.

What does the physician state on the LCR-1040A?

Whether the applicant is physically and mentally able to care for persons with developmental disabilities. The physician completes the Physician Statement on page 2 after the applicant has filled in the health self-disclosure on page 1, and dates it within six months of the application.