AHCCCS Eligibility Policy Manual - Transmittal 71 - Additional Forms that can be used to Declare U.S. Citizenship or Non-Citizen Status

Eligibility Policy Manual

Transmittal #71

Subject: Additional Forms that can be used to Declare U.S. Citizenship or Non-Citizen Status

Implementation Date: October 3, 2008

MS 508.02.B is revised to add additional forms that can be used to declare U.S. citizenship or non-citizen status.

MS 508.02.B and MS 522.02.B are both revised to clarify who can sign the declarations (i.e., the declaration of U.S.citizenship if claiming to be a U.S.citizen, or declaration of USCIS status if claiming to be a non-citizen who is lawfully residing in the United States). When the customer has a legal representative (i.e., guardian or conservator) the declarations must be signed by the legal representative.

U.S. Citizenship must be attested to by signing one of the following:

The Statement of Citizenship (DE-140),
Application for AHCCCS Health Insurance (AH-001),
Application for Arizona Long Term Care System (ALTCS) (DE-102),
The ACE generated ALTCS Application form,
The ACE generated Renewal of ALTCS Benefits form,
The ACE generated SSI MAO Renewal form,
Application for AHCCCS Health Insurance and Medicare Cost Sharing Benefits (DE-103),
The DES application form, or
The Health-E-Arizona Application form. (This form must be signed on the last page of the application or a signed copy of the last page of the AH-001 must be provided.)

In order for the application or renewal form to be acceptable as a declaration of U.S.citizenship, it must:

Have the question about U.S. citizen answered "Yes" or show a US place of birth (for ACE generated applications or ACE generated renewal forms, the application or renewal form will need to show U.S. citizen), and
Be signed by using the following guidelines:

If the customer is...	THEN obtain the signature of...
An adult	The customer's legal representative (i.e., conservator or guardian) if the customer has one. When there is no legal representative: The customer, or The customer's spouse, or For KidsCare, other unmarried parent of a child in common (if the child is also applying), or Another adult (if a Physician Statement of Incapacity, DE-217, has been obtained).
A child	The parent or legal representative.

The signature guidelines also apply to the Statement of Citizenship form (DE-140) and the Statement of Lawful Permanent Resident Status form (DE-141).

MS 522.02.B is also revised to indicate that the ACE generated ALTCS Application form and the ACE generated Renewal of ALTCS Benefits form can be used to declare USCIS status if the application or renewal form shows a person's USCIS status (lawful permanent resident, refugee, etc.), and the application or renewal form is signed using the signature guidelines described above (signature guidelines are also in MS 522.02.B).

MS 508.02.A is revised at the second NOTE to add information that the RP135 Demographics PMMIS screen should not be printed and scanned into Fortis because this information will always be in PMMIS.

MS 508.02.J is revised to add a NOTE that if the Vital Records Data Base is used to document citizenship, print and scan the response into Fortis.

If you have questions about these instructions or need assistance, please contact:

For ALTCS, Dan McKeever at (602) 417-4455, Mary Coons at (602) 417-4136 or Yvette Hill at (602) 417-4131
For SSI MAO and MCS, Marque Collins at (602) 417-4365
For KidsCare, Kathy Tapija at (602) 417-4858.