Form Fa-001 - Application For Benefits (Page 10 of 31) in pdf

Do you need help with this application? Visit

or call 1-855-HEA-PLUS (432-7587).

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

For Agency Use Only

Arizona Health Care Cost Containment System (AHCCCS)

Date:

Application for Benefits

Group Number:

Contact Information:

Tell us how we can contact an adult member of your household.

Name (First, Middle, Last): _________________________________________________________________________________________

Home

Address:____________________________________

Apt. #: ____ City: ____________________ State: ____ Zip Code: ________

Mailing Address (if different):

_________________________

Apt. #: ____ City: ____________________ State: ____ Zip Code: ________

Do you live in a shelter?

 Yes

 No

If ‘Yes,’ what kind of shelter? ________________________________________________

Phone Number: __________________________ This number is:

 Home

 Cell

 Work

 Message

 Other: ___________

Other Phone Number: _____________________ This number is:

 Home

 Cell

 Work

 Message

 Other: ___________

What is the preferred SPOKEN household language?

 English

 Spanish

 Other: ____________________________________

What is the preferred WRITTEN household language?

 English

 Spanish

 Other: ____________________________________

I would like to get information about this application by:

Email:

 Yes

 No

Email address: ____________________________________________________________________________

Text:

 Yes

 No

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

I need the following help with this application (check all that apply):

 Reading/understanding this application

 Filling out this application

 Other: __________________________________

 American Sign Language

 Braille

 Language Interpreter Language: _____________

I need the following accommodations for this application (check all that apply):

 Hearing

 Speaking

 Seeing

 Writing

 Walking

 Other: ______________________________

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?

 Spanish

 Other: _________________________

English

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: ___________________________________________________________________________

Text:

 Yes

 No

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 customer, give permission for the person listed above

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

as my representative to act on my behalf in the process of qualifying me for

agree to:

help with insurance costs, help with Medicare costs, Nutrition Assistance,



Provide only truthful and complete information under penalty of perjury.

Cash Assistance, and/or Tuberculosis Control. I, 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 determine if

application.

the customer can qualify for help with healthcare costs, help with Medicare



Give permission for my representative to provide any documents

costs, Nutrition Assistance, Cash Assistance, and/or Tuberculosis Control, such

requested, including personal information.

as the customer’s Social Security number, income, assets, citizenship,



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

residency, medical insurance, and information about the customer’s spouse,

other people, businesses, or agencies to give personal information

minor children, and parents (if the customer is a minor child).

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



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

information needed to determine if I am disabled.

Has an increase or decrease in income;



Agree to give information about my personal circumstances to my

Has an increase or decrease in assets;

representative.

Changes ownership of assets, including opening or closing financial



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

accounts;

reimbursement claims to AHCCCS on my behalf.

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: _____________________________________________________

Date: __________________________________________________________

FA-001 (12-17)

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