Application Instructions
Who to include on the application:
If you are applying for you or someone in your family, list yourself and
everyone in your family who lives with you and is:
- Your spouse;
- Your child/stepchild under age 19;
- Your child/stepchild's child;
- Your child/stepchild's spouse;
- Your child's other parent; and
- A child related to you who you are caring for.
Include persons who normally live with you but are temporarily not living
with you because the person is working or is a child attending school.
If you are applying for someone else (your mother, grandparent, friend, etc.)
include the persons who are related (as listed above) to the person for whom you
are applying.
If others who are not related as listed above want to apply, complete a
separate application.
To speed up the processing of your application, send the information
listed below with your application.
-
Wages: Copies of check stubs or statement from employer showing
your gross earnings last month and this month. If someone listed on the
application lost a job within the last two months, send proof of the last
day worked and the gross amount of the last check received.
-
Self-Employment: Copies of current Federal tax forms: 1040, SE and
applicable schedule C, C-EZ, E, F, K-1, etc. or proof of business income and
expenses for the last calendar month.
-
Other Income: Proof of any other income or money received from any
source or for any reason, this and last month. This includes award letters
from the Social Security Administration, Veterans Administration, Railroad
Retirement, or other retirement or disability pension.
-
Health Insurance: A copy of insurance ID cards for persons who are
applying for medical benefits but who are currently covered by health
insurance or attach a piece of paper that lists the company name and policy
number.
-
Citizenship: Copies of both sides of citizenship or immigration
documents for persons who want medical coverage and were not born in the
United States or its territories. Receiving AHCCCS Medical Benefits will not
affect anyone's immigrant status. AHCCCS does not report any information
to the Immigration and Naturalization Service (INS).
-
Daycare: Proof of amount paid for the care of a child or
incapacitated adult so an adult in the household can work.
- Health Plan: Choose a health plan from the choices on the back of
the next page. Write your choice at the top of Page 1.
Please answer all questions. Use a pen, and print your answers
clearly.
Mail the completed application to:
AHCCCS Central Screening Unit
1209 E. Washington St. MD 400
Phoenix, AZ 85034
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