Form Aaa-1222a Lthpd - Telephone Assistance Program Client Instruction Sheet Page 2
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2AAA-1222A LTHPD (3-15)
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Division of Aging and Adult Services
TELEPHONE ASSISTANCE PROGRAM (TAP) CHECKSHEET
The Department of Economic Security, Corporation Commission and Century Link are jointly administering a
telephone assistance program in the state of Arizona. The program provides assistance for low-income persons
with a medical need. The application process is being conducted jointly by the Department of Economic Security
and local volunteer agencies. The program provides for the monthly basic rate, and assistance with installation
costs if needed. We are asking for your assistance in the determination of medical need in order for the household
to qualify for this benefit.
DOCTOR’S OFFICE USE ONLY
CONFIRMATION OF MEDICAL NEED
PATIENT’S NAME
PHONE NO.
PATIENT’S ADDRESS (No., Street, Apt. No, City, State Zip Code)
The patient has a medical condition that would require a telephone in the household. The medical condition will
require the availability of a telephone for approximately:
Up to one year
Two years or less
Three years
DOCTOR’S NAME
PHONE NO.
DOCTOR’S ADDRESS (No., Street, Suite No., City, State, Zip Code)
DOCTOR’S SIGNATURE
DATE
AGENCY USE ONLY
FAMILY SERVICE CENTER OR COMMUNITY ACTION PROGRAM (CAP)
YES NO
The home is wired for telephone service
Has the household had land-line telephone service in the past 90 days?
The doctor’s signed statement indicates applicant’s medical need.
The doctor’s signed statement indicates applicant’s medical crisis
The medical need will last (check appropriate box):
Up to one year
Two years or less
Three years
YES NO
Is the caseworker providing certification for TAP? (Worker certification is only valid for 1 year)
WORKER’S SIGNATURE
DATE
If you have any questions regarding this form, please call the TAP office
at 542-4446 or 1-800-582-5706.
THIS FORM IS ONLY VALID FOR 60 DAYS AFTER THE DOCTOR’S SIGNATURE DATE.
PLEASE, DO NOT MAIL THIS FORM. SEE INSTRUCTIONS ON REVERSE SIDE.
_______________________________________________________________________________________________________________________________________________________________________
1789 W. Jefferson, S/C 950A, Phoenix, AZ 85007 P.O. Box 6123, Phoenix, AZ 85005
Telephone (602) 542-4446 Fax (602) 542-6655
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