Form De-103 - Application For Ahcccs Health Insurance And Medicare Savings Programs (Page 7 of 10) in pdf

Has there been a change in any of your income during the last three months or do you expect a change in income?  Yes  No

If Yes, complete below. If you need more room, attach a separate piece of paper with the information requested.

Date of change or expected change

Type of income affected

What is the change?

POTENTIAL BENEFITS

Are you or your spouse a veteran?  Yes  No

 Yes  No

Are you the widow/widower of a veteran?

Have you, your spouse or your deceased spouse ever worked for a government agency, or employer with a disability or pension plan?  Yes  No

If you answered YES to any of these questions, provide the following information about the veteran or employee:

Name

Military ID Number

Date of Birth

Date of Death

Dates of employment and/or Military service

Employer’s address

Employer/Branch of Service

MEDICAL COVERAGE

Do you or your spouse have medical insurance coverage, other than Medicare?  Yes  No

If YES, complete the information below and SEND A COPY OF THE INSURANCE ID CARD.

Name of Insurance Company

Who is covered by Insurance

Do you or your spouse have an injury or illness resulting from an accident (pedestrian, automobile, or other vehicle, on the job, etc.)?  Yes  No

If YES, complete the items below:

Name and Address of Insurance or Company Responsible for Medical

Name

Type of Injury

Date of Injury

Costs due to the Injury

If eligible for AHCCCS Health Insurance or QMB, by signing this application, I agree to assign to AHCCCS all rights to third party payments of medical

expenses, including insurance coverage, to the extent that costs are paid by AHCCCS.

YOUR OPPORTUNITY TO REGISTER TO VOTE

If you are not registered to vote where you live now, would you like to apply to register to vote here today?

Applying to register or declining to register to vote will not affect the amount of assistance that you will be provided by this agency.

Ye s

If you do not check either box, you will be considered to have decided not to register to vote at this time.

If you would like help in filling out the voter registration application form, we will help you. The decision whether to seek or accept help is yours. You may fill

out the application form in private.

If you believe that someone has interfered with your right to register or to decline to register to vote, your right to privacy in deciding whether to register to vote,

or your right to choose your own political party or other political preference, you may file a complaint with the State Election Director, Secretary of State’s

Office, 1700 West Washington, Phoenix, AZ 85007, 602-542-8683.

You may also get a voter registration form at

HEALTH PLAN CHOICE

If you are applying for AHCCCS Health Insurance, choose an AHCCCS health plan that serves your county. See page D or a list of health plans.

Name of Health Plan you Choose (from page D)

PENALTY WARNING

The information provided on this form may be verified by federal, state, and local officials. If anything is inaccurate, you may be denied benefits.

1. You must not knowingly withhold or give false information with the intent to receive or to continue receiving AHCCCS benefits to which you are not entitled.

2. You will be required to pay back to AHCCCS any benefits you receive as a result of withholding or giving false information and you will be subject to

criminal prosecution.

It is fraud for any person to knowingly withhold information with the intent to receive or continue to receive benefits to which he/she is not eligible. Any person

found guilty of fraud may be subject to fines, criminal prosecution, imprisonment or other penalties as provided for by applicable State and Federal laws.

RELEASE OF INFORMATION

I authorize AHCCCS to investigate and contact any sources necessary to establish eligibility and the accuracy of financial information that pertains to

AHCCCS eligibility.

STATEMENT OF TRUTH

I swear or affirm under penalty of perjury that the oral or written statements made regarding the persons in my home, my income, and any other items that

pertain to my possible eligibility for AHCCCS Health Insurance or Medicare Savings Program benefits are true and correct to the best of my knowledge and

that any photocopies I have provided are the same as the original. I have read and understand the penalty warning. I have read and understand my rights

and responsibilities, and providing Social Security numbers on page C of this application. I further agree to cooperate with Arizona or Federal personnel in the

completion of a quality control review on my eligibility for benefits. I certify that the citizenship/immigration status is correct for each person applying. I do not

have to give information on citizenship or immigration status of family members who are not applying for healthcare benefits. I understand that my records will

be kept confidential and will only be released for purposes authorized by federal and state law.

Signature of Applicant

Date

Signature of Witness (if applicant signed with a mark)

Date

Signature of Spouse

Date

Signature of Representative

Date