Form Fa-001 - Application For Benefits Page 17
ADVERTISEMENT
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31Do you need help with this application? Visit
or call 1-855-HEA-PLUS (432-7587).
Help with Health Insurance Costs, Help with Medicare Costs, and Cash Assistance
Complete this section for anyone who is applying for help with insurance costs and/or help with Medicare
Questions:
costs, and/or Cash Assistance.
Who?
Number of Babies
Expected Due Date
Due
Is anyone you are applying
Yes
No
for pregnant?
For anyone applying under age 19, are both of his/her parents living in the home?
Yes
No
If No, complete the information below:
Child’s Name
Parent’s Name (First, Last)
Social Security Number
Date of Birth
Mailing Address
City, State
Zip Code
Phone Number:
Reason parent is absent: Deceased Out of Home
Unknown
Child’s Name
Parent’s Name (First, Last)
Social Security Number
Date of Birth
Mailing Address
City, State
Zip Code
Phone Number:
Reason parent is absent: Deceased Out of Home
Unknown
Child’s Name
Parent’s Name (First, Last)
Social Security Number
Date of Birth
Mailing Address
City, State
Zip Code
Phone Number:
Reason parent is absent: Deceased Out of Home
Unknown
Child’s Name
Parent’s Name (First, Last)
Social Security Number
Date of Birth
Mailing Address
City, State
Zip Code
Phone Number:
Reason parent is absent: Deceased Out of Home
Unknown
Has anyone ever received
Supplemental Security Income (SSI)?
Yes No
Who? ________________________________
Does anyone have Medicare
Medicare Claim or Railroad Retirement Number
Who? ______________
Coverage?
Yes
No
______________________
Part A – Hospital Insurance
___________________
Part B – Medical Insurance
Part D – Prescription Drug Plan
Medicare Claim or Railroad Retirement Number
Who? ______________
______________________
Part A – Hospital Insurance
___________________
Part B – Medical Insurance
Part D – Prescription Drug Plan
Answer the following questions for anyone who is applying for benefits.
Foster Care and Adult with Child:
Was anyone in Arizona Foster Care on
Who? _______________________________________
Yes
No
th
his/her 18
birthday?
Who? ______________________________________
Was anyone in Arizona Tribal Foster
Yes
No
th
Care on his/her 18
birthday?
What Tribe? _________________________________
Does any adult live with at least one
Who? ______________________________________
child under age 19 and is the main
Yes
No
caretaker of the child?
FA-001 (12-17)
Page
8
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Legal