Form Ddd-1469a Forff - Spouse Attendant Care Acknowledgment Of Understanding
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1
2ARIZONA DEPARTMENT OF ECONOMIC SECURITY
DDD-1469A FORFF (10-16)
Page 1 of 2
Division of Developmental Disabilities
SPOUSE ATTENDANT CARE ACKNOWLEDGMENT OF UNDERSTANDING
MEMBER’S NAME
AHCCCS ID NO.
SPOUSE’S NAME
SUPPORT COORDINATOR’S NAME
We, the people who have signed on the next page, choose to have Arizona Long Term Care (ALTCS) pay
(hereafter referred to as the Spouse) for the attendant care of
(hereafter referred to as the Consumer).
We know and agree that:
•
The ALTCS Support Coordinator will decide the number of hours that will be paid for the Member’s care;
•
All services will be medically necessary and cost effective; and
•
We cannot have more than 40 hours of Attendant Care (or similar services) in a seven-day period.
We know and agree that if the Spouse is paid for giving care:
•
There will be an increase in the earned income of the Spouse;
•
The extra income could cause us to lose benefits from other publicly funded programs; and
•
This change in benefits could affect us and/or others in our household.
Publicly-funded programs may include but are not limited to the following:
BENEFIT TYPE
AGENCY RESPONSIBLE
PHONE NUMBER
AHCCCS, ALTCS and/or KidsCare Eligibility
AHCCCS
Supplemental Security Income (SSI)
Social Security Administration
Medicare Part D Low Income Subsidy
Social Security Administration
Nutrition Assistance
Arizona Department of Economic Security
Temporary Assistance to Needy Families (TANF)
Arizona Department of Economic Security
General Assistance
Arizona Department of Economic Security
Housing and Urban Development (HUD)
Local Housing Authority
Social Security Disability
Social Security Administration
Qualified Medical Beneficiary (QMB)
AHCCCS
Specified Low-Income Medicare Beneficiary (SLMB)
AHCCCS
Qualified Individual -1 (QI-1)
AHCCCS
Other:
Other:
Other:
Other:
See page 2 for EOE/ADA/LEP/GINA disclosures
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