Form Fa-001 - Application For Benefits (Page 6 of 31) in pdf

Do you need help with this application? Visit

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

What is expected of me?

For all programs:

• You must provide DES and/or AHCCCS with the needed information to correctly determine your

eligibility and authorize DES and/or AHCCCS to investigate and contact any sources necessary to

confirm the accuracy of the information for your eligibility.

• If you are approved for benefits, you will get a letter telling you what changes you must report. You

MUST report your changes timely.

Program-specific expectations:

If applying for help with AHCCCS Medical Assistance, help with Medicare costs, and/or Cash

Assistance, you must take necessary steps to obtain any annuities, pensions, retirement and disability

benefits to which you may be entitled, including, but not limited to, Social Security benefits, Railroad

retirement, Veterans benefits and unemployment compensation.

For AHCCCS Medical Assistance and/or Cash Assistance, you must give us any information you

have about an absent parent. If you have reason for not providing this information (such as adoption

pending, abuse, incest, neglect, etc.) you may claim good cause. You must cooperate with the

Division of Child Support Services (DCSS) to establish paternity, unless you can prove good cause.

For Nutrition Assistance and/or Cash Assistance you must tell us and provide proof to receive

deductions, for the following expenses: court ordered child support paid, child/adult dependent care

expenses, medical expenses, transportation costs to and from the provider of medical care or daily

care of a child/adult dependent, rent or mortgage payments, utility or other shelter costs.

What are my rights?

You have the RIGHT to:

• Courteous and professional treatment.

• Be treated fairly and equally regardless of race, color, religion, national origin, sex, age, disability, or

political beliefs.

• Apply for benefits and be given a letter that tells you if you are eligible or not, and/or get a letter before

your benefits are reduced or stopped.

• Review DES and AHCCCS policy manuals that show the rules and regulations of AHCCCS Medical

Assistance, Medicare Savings Program, Nutrition Assistance, Cash Assistance, and Tuberculosis

Control if you want to know the reason for our decision.

• Talk about your case with a worker or supervisor.

• Have all information you give regarding your eligibility kept private according to state and federal law.

• Ask for a fair hearing if you disagree with your application being denied, your benefits ended, or are

being reduced, or if a decision is not made on your application within the allowable number of days and

the delay is due to DES or AHCCCS.

• Look at your file before a fair hearing.

• Bring an attorney or any other person to a fair hearing.

• File for Nutrition Assistance benefits separately or at the same time you apply for other programs listed

on the application. All Nutrition Assistance applications, regardless of whether they are joint

applications or separate applications, must be processed for Nutrition Assistance purposes in

accordance with procedural, timeliness, notice and fair hearing requirements. No household shall have

its Nutrition Assistance benefits denied solely on the basis that another program applied for has been

denied. A separate determination for Nutrition Assistance must be completed. When another program

that is applied for is denied a new application for Nutrition Assistance shall not be required. Eligibility

shall be determined based on Nutrition Assistance processing time frames from the date the joint

application was initially accepted by the State agency.

Form:

To file a discrimination complaint, contact:

U.S. Department of Health and Human Services

U.S. Department of Agriculture

Director, Office for Civil Rights

Director, Office of Adjudication

Room 515-F

1400 Independence Avenue, SW

200 Independence Avenue, S.W.

Washington, DC 20250-9410

Washington, DC 20201

1-202-619-0403 (voice)

Fax: 1- 202-690-7442

1-800-537-7697 (TTY)

Email:

program.intake@usda.gov

For help filling out the form, you may call:

1-866-632-9992 (Toll- free Customer Service)

1-800-877-8339 (Local or Federal relay)

FA-001 (12-17)

1-866-377-8642 (Relay voice users)

Page F

Form Fa-001 - Application For Benefits Page 6

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