Form Dd-525 - Application For Eligibility Determination Page 4
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5DD-525 (9-17) PAGE 4
NAME (Last, First, M.I.)
DATE OF BIRTH
Who is allowed to sign the application?
•
An applicant over 18 years of age without a legal guardian
•
A biological or adoptive parent applying for a minor child
•
A Case Manager from the Department of Child Safety, for children in foster care
•
A legal guardian, appointed by a court
I am applying as or for the person named above who is a resident of the State of Arizona. I have been informed
of the services provided by this agency. I understand that if I am referred to AHCCCS for an ALTCS eligibility
determination, I must cooperate in this determination process. As part of my application to this Division, I have been
informed of the DDD eligibility criteria and of my rights relevant to the application process. As a condition of eligibility
for DDD, applicants are required to assign rights to insurance benefits in accordance with R6-6-1303. If I am eligible
and assigned to services, I authorize the release of information necessary to file a claim to my insurance company.
RESPONSIBLE PERSON NAME (Please print)
RELATIONSHIP TO APPLICANT (
i.e. parent, court appointed guardian, self)
RESPONSIBLE PERSON’S SIGNATURE
DATE
APPLICANT STOP HERE
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Parent category: Legal