Form Fa-001-K - Kidscare Application Addendum Page 2
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2FA-001-K (7-16) - Reverse
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Family Assistance Administration
KIDSCARE APPLICATION ADDENDUM CONTINUED
Why did the health insurance coverage stop?
Cost too much
Coverage was through Medicaid/CHIP, or through Advance Premium Tax Credits (APTC), or Cost Sharing Reductions
Divorce or death of parent
Employer stopped offering coverage for dependents
Other: __________________________________________________________________________________________________________
If the health insurance cost is too much:
The monthly premium to cover one person is:
$
The monthly premium to cover one family is:
$
Was approved for APTC because employer-sponsored insurance was determined to be unaffordable.
Do any children under the age of 19 you are applying for have a chronic illness?
(Medical condition that requires frequent and ongoing treatment and that if not
Yes
No
properly treated will seriously affect the person’s overall health).
If yes, who and what is the chronic illness?
Name of Child
Description of Chronic Illness
Premiums
Most people do not have to pay a monthly premium for AHCCCS Medical Assistance.
I understand that I may be required to pay a premium if enrolled in the KidsCare program.
Some people with income too high to qualify for AHCCCS Medical Assistance with no monthly premium may be able to get it by paying a
monthly premium. If you have to pay a premium, the premium amounts are:
$10 to $70 for customers on the KidsCare program.
STATEMENT OF TRUTH:
I swear under penalty of perjury that the statements made about persons in my home, income, assets, property and all other information I have given
DES and their contractors that relates to my eligibility for benefits is true and correct to the best of my knowledge, and that I have not withheld any
information.
APPLICANT’S SIGNATURE
DATE
AGENCY USE ONLY
CASE NUMBER
MAIL CODE
DATE COMPLETED
APPLICATION DATE
SIGNATURE OF DES OR TANF AGENCY EMPLOYEE WHO HELPED COMPLETE THE ASSISTANCE APPLICATION ADDENDUM
INTERVIEWER’S SIGNATURE
DATE
The USDA is an equal opportunity provider and employer • DES/TANF Agencies are Equal Opportunity Employers/Programs •
Under Titles VI and VII of the Civil Rights Act of 1964 (Title VI & VII), and the Americans with Disabilities Act of 1990 (ADA),
Section 504 of the Rehabilitation Act of 1973, the Age Discrimination Act of 1975, and Title II of the Genetic Information
Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in admissions, programs, services, activities, or
employment based on race, color, religion, sex, national origin, age, disability, genetics and retaliation. To request this
document in alternative format or for further information about this policy, contact your local office; TTY/TDD Services: 7-1-1.
• Free language assistance for DES services is available upon request. • Ayuda gratuita con traducciones relacionadas con los
servicios del DES esta disponible a solicitud del cliente.
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