Form Fa-001 - Application For Benefits printable pdf download

Arizona Department of Economic Security/Family Assistance Administration (DES/FAA)

Arizona Health Care Cost Containment System (AHCCCS)

Application for Benefits

Tear off and keep pages A through I for your records.

What is this application for?

Use this application to see if you and members of your household qualify for:



Free or low-cost insurance from AHCCCS



Help with your Medicare costs



Nutrition Assistance



Cash Assistance/Temporary Assistance for Needy Families (TANF)



Tuberculosis Control



A new tax credit that can help pay your health insurance premiums

See page B for a description of each program.

Who can use this application?

An application may be completed by you or anyone you choose who knows or can get the information needed to complete the

application for you and your household members. You can use this application to apply for anyone in your household, even if they

already have benefits, including health insurance.

Your household includes:

•

Your spouse, if married

•

Your children under age 22 who live with you

•

Your partner who lives with you (but only if you have a child together who needs health insurance or Cash Assistance)

•

People you claim on your income tax return even if they do not live with you

•

Relatives in your care who are under the age of 19 and live with you

•

People who you live with who purchase and prepare food with you

If you want to select a representative to complete your application, complete the Authorized Representative form on page 1 of the

application.

Where else can I apply?

You can apply faster online at

You can also apply in person at any local Department of Economic Security (DES)/Family Assistance Administration (FAA) office.

You can find a list of local FAA offices at

or call our 24 hour Interactive Voice Response system at 1-855-HEA-

PLUS (432-7587).

What information do I need to complete this application?

For everyone in your household, you may need:



Birth dates



Social Security numbers



Employer and income information for everyone in your household



Resources (e.g., bank account, cash, property)



Expenses



Information for any current health insurance



Information about any job-related health insurance available to members of your household



Other information needed to complete your application

Note: You can file an application with only your name, address, and the signature of a responsible household member or your

authorized representative. This will hold your date of application but eligibility cannot be determined until you complete a full

application and an interview, if needed. Benefits are provided from the date the agency receives the application.

Why do we ask for so much information?

We ask about income and other information to make sure you and members of your household get the correct benefits for your

household.

We will keep all information you provide private, as required by law.

What happens next?

Send your completed, signed application to the address on Page 17 or take it to your local DES office. If you do not have all of the

information available, you can still submit your application and we will help you get the rest of the information.

What if I need help?

If you need help filling out this application, please tell us. If you need a language interpreter or accommodations for a disability, please

check the kind of help you need on page 1 of the application.

Online:

Phone: 1-855-HEA-PLUS (432-7587)

In person: Visit to find the office closest to you.

Page A

FA-001 (12-2017)

Form Fa-001 - Application For Benefits

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