| |
|
|
|
|
Designation of EBT Alternate Card Holder [ FAA-1004A ]
Use this form to add a person who you want to have access to your Nutrition Assistance or TANF Cash Assistance benefits or remove a person who currently has access to your benefits.
|
|
|
|
Separate Household Status Statement [ FAA-0255A ]
Use this form when you are applying for Nutrition Assistance to tell DES who buys and cooks food with you and the persons in your household.
|
|
|
|
Cash Programs Personal Responsibility Agreement (PRA) [ FAA-1523A ]
This form must be signed by the head of household and the other parent when both parents are living in the home and applying for TANF Cash Assistance.
|
|
|
|
Illegal Drug Use Statement [ FAA-1415A ]
Each person age 18 or older who was approved for or is renewing eligibility for TANF Cash Assistance must complete one of these forms.
|
|
|
|
Disability Report [ DE-121 ]
Persons under age 65 who are applying for AHCCCS for Seniors and People with Disabilities or AHCCCS Freedom to Work may need to complete this form to establish disability.
|
|
|
|
Authorization for the Disclosure of Protected Health Information [ DE-202 ]
This form authorizes medical providers to give medical information to the Arizona Department of Economic Security, Disability Determination Services Administration to determine if you have a disability.
|
|
|
|
Recent Employment/Training Background [ FAA-0155A ]
This form is only used for the TANF Cash Assistance Two Parent Employment Program (TPEP). A separate form must be completed by each parent to determine the primary wage earner.
|
|
|
|
Verification of Living Arrangements/Residential Address [ FAA-0065A ]
This form is used to provide verification of the household’s residential address, the persons living in the home and housing and utility expenses. It must be completed by the landlord or a non-relative who is not living in the household.
|
|
|
|
Authorized Representative [ DE-112 ]
This form is used by an applicant to designate another person or organization to submit Nutrition Assistance, Cash Assistance, and Medical Assistance applications and act on the applicant’s behalf.
|
|
|
|
Health Insurance Marketplace Employer Coverage Tool [ EMP FN1 ]
Use this tool to gather answers about any employer health coverage that you’re eligible for (even if it’s from another person’s job, like a parent or spouse). You’ll need this information to complete your Marketplace application, even if you don’t accept the employer insurance you’re eligible for.
|
|
|
|
Changes - What You Need to Know [ FAA-1760A ]
How to report a change.
|
|
|
|
Request for Quarters of Coverage (QC) History Based on Relationship [ SSA-513 ]
Request For Quarters Of Coverage (QC) History Based On
Relationship
|
|
|
|
Application for Benefits [ FAA-0001A ]
This form is used as an application for Cash Assistance, Nutrition Assistance and Medical Assistance benefits.
|
|
|
|
Change Report [ FAA-0412A ]
This form is used to report changes in your household circumstances.
|
|
|
|
Youth in Tribal Foster Care Update [ MA-436 ]
Children in Tribal foster placements are potentially eligible for AHCCCS Medical Assistance. This form was
designed for Tribal Social Services/Foster Care staff to use by itself to report a change in placement for a child that is currently receiving AHCCCS, or as a cover sheet when applying for AHCCCS on behalf of a child in Tribal Foster Care.
|
|
|
|
Nutrition Assistance Drug Testing Agreement [ FAA-1565A ]
This form is used for a person who is convicted of a felony offense which has an element of the offense “the use or possession of a controlled substance” to qualify the person to be potentially eligible for Nutrition Assistance. The person must agree to random drug testing and meet at least one of the requirements listed on the form.
|
|
|
|
AHCCCS Release of Information Authorization [ DE-200 ]
This form is completed and signed by the applicant(s) to give permission for other organizations to release information needed to determine eligibility for AHCCCS related medical programs.
|
|
|
|
Verification of New/Current Employment [ FAA-0053A ]
This form is used to verify new and current employment history.
|
|
|
|
Request to Voluntarily Withdraw from an Appeal [ FAA-1693A ]
This form is used to withdraw a request for an appeal.
|
|
|
|
Verification of School Attendance [ FAA-0075A ]
This form is used to verify school attendance for Cash Assistance and Nutrition Assistance.
|
|
|
|
Request for Verification of Unearned Income [ Unearned Income ]
This form is used to provide proof of unearned income.
|
|
|
|
Request for Verification of Annuity [ DE-235 ]
This form is used to provide annuity information for AHCCCS Medical Assistance.
|
|
|
|
Request for Verification of Money Borrowed [ DE-230 ]
This form is used for all programs to verify money borrowed.
|
|
|
|
Referral for Potential Benefits [ Potential Benefits ]
This form is used for Cash Assistance to verify that a person has applied for potential benefits.
|
|
|
|
Referral for Social Security Benefits [ SSA Benefits ]
This form is used for Cash Assistance to verify that a person has applied for potential benefits.
|
|
|
|
Referral for Veterans Benefits [ Veterans Benefits ]
This form is used for Cash Assistance to verify that a person has applied for potential benefits.
|
|
|
|
Authority to Release Student Information [ FAA-0060A ]
This form is used to authorize the release of student information.
|
|
|
|
Nutrition Assistance Able Bodied Adult Without Dependents ABAWD Time Limits [ FAA-1530A ]
Arizona has a 3-month time limit for Able Bodied Adults Without Dependents (ABAWDs) who receive Nutrition Assistance benefits in a 36-month period. ABAWDs can get Nutrition Assistance benefits in only three (3) months out of 36 months unless they qualify for an exemption.
|
|
|
|
General Delivery Service [ OPS 1-12 ]
This form is used to request establishment of general delivery service for no more than 30 days from the date of request.
|
|
|
|
DES Authority to Release Records [ FAA-0059A ]
This form is used as an official request for an FAA (DES) case file.
|
|
|
|
Declarations for Medical Assistance, Nutrition Assistance and Cash Assistance [ FAA-1724A-HEAplus ]
This form is the Health-e-Arizona Plus Declarations for Medical Assistance, Nutrition Assistance and Cash Assistance, and can be used to provide additional signatures for your application.
|
|
|
|
Verification of Terminated Employment [ FAA-1701A ]
This form is used to verify terminated employment history.
|
|
|
|
Additional Questions for Children Under Age 19 [ KidsCare ]
This form is used to answer questions for children under age 19, to help determine if the children can qualify for KidsCare if income is too high to qualify for free Medical Assistance benefits.
|
|
|
|
Verification of Other Income [ FAA-1725A ]
This form is used to verify other income, such as cash gifts, loans, cash contributions, in-kind income and vendor payments.
|
|
|
|
Participant Statement Verification Worksheet [ FAA-1111A ]
This form is used when every effort to provide documents or collateral contact information has been made, and you are unable to provide the verification.
|
|
|
|
DES Authority to Release Information [ FAA-1765A ]
This form is completed and signed by the applicant(s) to give permission for other organizations to release information needed to determine eligibility for DES programs.
|
|
|
|
Consent for an Assistor [ A-000 ]
This form is used by customers to authorize community partner organizations to submit HEAplus applications on their behalf.
|
|
|
|
Elderly Simplified Application Project (ESAP) Nutrition Assistance Application [ FAA-1821A ]
You may use this application to apply when you and anyone you are applying for are 60 years old or older and receive no income from work or self-employment.
|
|
|
|
Update Your Contact Information and Go Paperless! [ AHCCCS2 ]
Learn how to update your contact information to make sure AHCCCS can reach you, and sign up for text or email alerts from AHCCCS.
|
|
|
|
AHCCCS Connect Mobile Terms of Service [ AHCCCS3 ]
AHCCCS Connect Mobile Terms of Service
|
|
|
|
AHCCCS Connect Privacy Policy [ AHCCCS4 ]
AHCCCS Connect Privacy Policy
|
|
|
|
Hearing Request [ FAA-0098A ]
Use this form to file an appeal and request a fair hearing.
|
|
|
|
Application Signature Pages [ FAA-1724A ]
This form is the Health-e-Arizona Plus Declarations for Medical Assistance, Nutrition Assistance and Cash Assistance, and can be used to provide additional signatures for your application.
|
|
|
|
ALTCS - AHCCCS Release of Information Authorization [ ALTCS DE-200 ]
This form is completed and signed by the applicant(s) to give permission for other organizations to release information needed to determine eligibility for AHCCCS related medical programs.
|
|
|
|
ALTCS - Authorized Representative [ ALTCS DE-112 ]
This form is used by an applicant to designate another person or organization to submit Nutrition Assistance, Cash Assistance, and Medical Assistance applications and act on the applicant’s behalf.
|