Form De-103 - Application For Ahcccs Health Insurance And Medicare Savings Programs (Page 5 of 10) in pdf

Form De-103 - Application For Ahcccs Health Insurance And Medicare Savings Programs Page 5

AHCCCS APPLICATION

FORM

 YES

 NO

Are you applying for AHCCCS Health Insurance?

 YES

 NO

Are you applying for help to pay Medicare costs?

APPLICANT INFORMATION

First Name

Last Name

Social Security Number

 Male

 Female

Date of Birth

Age

Are you:

Medicare Claim Number

 U.S.A

 Other Country

Place of Birth

Are you a U.S. Citizen?

What is your immigration status?

❑Asylee

❑Afghan/Iraqi Special Immigrant

❑Refugee

❑Yes, a U.S. citizen

❑Battered Alien

❑American Indian Born in Canada

❑Conditional Entrant

❑No, not a U.S. citizen

❑ Cuban-Haitian Entrant

❑Deportation Withheld

❑ Hmong or Laotian Highlander

If no, what number is on your

❑Indefinite Detainee

❑Lawful Permanent Resident (LPR) ❑Parolee for at Least One Year

immigration card?

❑Victim of Trafficking

❑Other

A_________________________

Home Address

City

State

Zip Code

Mailing Address (if different)

City

State

Zip Code

Home Phone Number

Work Phone Number

Message Number

Email Address

English

Spanish

Other ________________

What language do you speak?

English

Spanish

Other _________________

What language do you read?

Ethnic Group - Optional (will not affect eligibility) ❑ Hispanic

❑ Non-Hispanic Latino

 White

 Asian

 Native American Tribe:

Race - (Select one or more) (Optional)

 Black/African American

 Hawaiian or other Pacific Islander

Alaska Native

 Never Married

 Married

 Divorced

Check your current Marital Status:

Effective Date of Current Marital Status:

 Common-Law

 Widowed

 Y

 No

If married, do you and your spouse live together?

If NO, date of separation:

Do you need help paying for medical bills from the last three months?  Yes

 No

What months? ___________________________

___________________________

 Yes

 No

Would you like to register to vote?

If you want to allow someone else to represent you or you have a legal guardian, provide the information below.

Representative’s First and Last Name

Representative’s Relationship to You

Representative’s Phone Number

Representative’s Mailing Address

City, State

Zip Code

Email Address

By signing below, I:

• Give permission for my representative to complete and sign my application;

• Give permission for my representative to provide any documents requested, including personal information;

• Give permission to my representative to sign on my behalf to permit other people, businesses, or agencies to give personal information

about me to AHCCCS;

• Give permission for AHCCCS or DES to tell my representative about my eligibility; and

• Agree to give personal information to my representative.

Signature of Applicant

Date:

(not needed if you have a legal guardian or you are unable to sign because you are

incapacitated):

Page 1

DE-103 (Rev. 06/2017)

Form De-103 - Application For Ahcccs Health Insurance And Medicare Savings Programs Page 5

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