Form Fa-001-K - Kidscare Application Addendum
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2FA-001-K (7-16)
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Family Assistance Administration
KIDSCARE APPLICATION ADDENDUM
Name (Last, First, Middle)
Soc. Sec. No.
Application ID
Health Insurance Coverage
Answer the following questions if you are applying for AHCCCS Medical Assistance for someone under age 19.
Does any child under age 19 in this application qualify for State employee
health benefits (even if they choose not to enroll) because:
·
A parent or step parent (in or out of the home) works for a State
agency and is eligible for health insurance through the State of
Yes
No
Arizona; or
·
The child or child’s spouse works for a State agency and is eligible
for health insurance through the state of Arizona?
Name of Child
Have any children under the age of 19 lost health insurance coverage in the
last 90 days?
Yes
No
·
If ‘Yes,’ give the following information:
Name of Child
Name of Policy Holder
Name of Insurance Company
Coverage
Group Number
Policy Number
Insurance Company Phone No.
End Date
See reverse for EOE/ADA/LEP/GINA disclosures
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Parent category: Legal