Form Fa-001-P - Application Signature Pages (Page 2 of 4) in pdf

Authorized Representative

This section is OPTIONAL. You may authorize someone else to represent you in the application process. DES and/or AHCCCS

cannot release any information about your eligibility without your written consent.

Representative’s Name: _____________________________________________ Is representative your legal guardian?  Yes  No

Representative’s Mailing Address: __________________________________ City: ________________ State: ____ Zip Code: ______

Representative’s Phone Number: ___________________This number is:  Home  Cell  Work  Message  Other: _______

Representative’s Other Phone Number: ______________This number is:  Home  Cell  Work  Message  Other: _______

What is the representative’s preferred SPOKEN language?

 English

 Spanish

 Other: _________________________

What is the representative’s preferred WRITTEN language?

 English

 Spanish

 Other: _________________________

My representative would like to get information about this application by:

Email:  Yes  No

Email address: ___________________________________________________________________________

 Yes  No

Text:

Number to text (standard text rates apply): _____________________________________________________

If ‘Yes’ is not marked for Email or Text, all information for this application will be sent via U.S. Mail to the mailing address provided.

By signing below I, the representative, agree to act on the customer’s

By signing below I, the customer, give permission for the person listed

above as my representative to act on my behalf in the process of

behalf. I also agree to:



qualifying me for AHCCCS Medical Assistance, help with Medicare costs,

Provide only truthful and complete information under penalty of

Nutrition Assistance, Cash Assistance, and/or Tuberculosis Control. I,

perjury.



therefore:

Fill in and sign needed forms.



Give permission for my representative to complete and sign my

Obtain and give to DES and/or AHCCCS all information needed to

application.

determine if the customer can qualify for help with healthcare costs,



Give permission for my representative to provide any documents

help with Medicare costs, Nutrition Assistance, Cash Assistance,

and/or Tuberculosis Control, such as the customer’s Social Security

requested, including personal information.



Give permission to my representative to sign on my behalf to permit

number, income, assets, citizenship, residency, medical insurance,

and information about the customer’s spouse, minor children, and

other people, businesses, or agencies to give personal information

about me to DES and/or AHCCCS, including protected health

parents (if the customer is a minor child).



information needed to determine if I am disabled.

Tell DES and/or AHCCCS right away if the customer:



Agree to give information about my personal circumstances to my

Has an increase or decrease in income;



representative.

Has an increase or decrease in assets;



Agree to allow my representative to assign all my rights to medical

Changes ownership of assets, including opening or closing financial

reimbursement claims to AHCCCS on my behalf.

accounts;



Has a change in address; or



Has a change in health insurance or the amount of premiums paid.

If I am determined eligible, this authorization will stay in effect until I or my representative tells you to stop it. This authorization will expire when my

application for assistance is withdrawn or denied, or when my eligibility ends. However, this authorization will continue during any time while I am

contesting my eligibility in an administrative hearing or court proceeding.

Signature of Applicant: _______________________________________

Signature of Representative: ___________________________________

Date: _____________________________________________________

Voter Registration

Tell us if any person over the age of 18 listed on this application would like to register to vote. If ‘Yes,’ we will mail a voter registration

form.

You may also access a voter registration form at If you would like help 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. Your answer to this question will not impact the programs you are eligible for.

 Yes

 No

 Already registered to vote

Would any person on this application over the age of 18 like to register to vote?

If YES is not checked, all persons over the age of 18 on this application will be considered to have decided not to register to vote at this time.

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:

State Election Director

Secretary of State’s Office

1700 West Washington

Phoenix, AZ 85007

602-542-8683

FA-001-P (Signature pages only) (7-17)

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