Application For AHCCCS Medical Assistance and Medicare Savings Programs
You can apply online by using Health-e-Arizona Plus at www.healthearizonaplus.gov	
Keep Pages A, B, C, D, E, F, and G for your records

If you are over age 65, blind or disabled, or if you are eligible for Medicare, use this application to apply for AHCCCS Medical Assistance and/or Medicare Savings Programs. Or, you can apply online at www.healthearizonaplus.gov.

How can I qualify for AHCCCS Medical Assistance?
•	Your gross monthly income can be no more than $1,383 for an individual or $1,869 for a couple (after a $20 standard deduction and other allowed deductions if you have earned income and/or dependent children).
•	You must be a resident of the state of Arizona and a United States citizen or a non-citizen who meets Medicaid requirements.
•	If you are under age 65 and not receiving Social Security Disability income, a disability determination will be part of your application process.

How can I qualify for a Medicare Savings Program?
If you are receiving or eligible for Medicare Part A, use this application to apply for help with your Medicare premium(s), copayments and deductibles. There are three Medicare Savings Programs. Each one has a different income limit and different benefits.	
Medicare Savings Program 	Qualified Medicare
Beneficiary (QMB)	Specified Low-Income Beneficiary (SLMB)	Qualified
Individual – 1 (QI-1)	
General Eligibility Requirements:	•You must be a resident of the state of Arizona.
•You must be a United States citizen or a non-citizen who meets Medicaid requirements.
•You must apply for pension, disability or retirement benefits if potentially 
available to you.	
Monthly Income Limits
(after allowed deductions):	Individual	Couple	Individual	Couple	Individual	Couple	
	$0 - $1,305	$0 - $1,763	$1,305.01 - $1,565	$1,763.01 - $2,115	$1,565.01 - $1,761	$2,115.01- $2,380	
Specific Requirements:	Receiving or eligible for
Medicare Part A	Receiving
Medicare Part A	Receiving
Medicare Part A	
What is the Benefit?	•	Pays your Medicare Part B Premium
•	Pays your Medicare
	Part A Premium (if not free)
•	Pays your Medicare coinsurance
•	Pays your Medicare Deductibles*	•	Pays your Medicare Part B Premium	•	Pays your Medicare Part B Premium	
*If you are enrolled with a Medicare HMO, your co-pays will also be paid. If you elect additional coverage from a Medicare HMO, you will be responsible for any additional premiums and costs.

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What services does AHCCCS Medical Assistance cover?	
•	Prescription medication*	•	Medical supplies	•	Medically necessary transportation	
•	Doctor’s office visits	•	Chemotherapy	•	Medically necessary specialist care	
•	Hospital services	•	Behavioral health care	•	Laboratory and X-ray services	
•	Dialysis	•	Immunizations (shots)	•	Rehabilitation services	
•	90 days of nursing care services	•	Emergency medical care	•	Chiropractic services	
*AHCCCS prescription coverage is limited for people who have Medicare.
What does AHCCCS Medical Assistance cost?	
Premiums	
Most people do not have to pay a monthly premium for AHCCCS Medical Assistance. 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 monthly premium amounts are:	
•	$10 - $70 for KidsCare	
•	$10 - $35 per person for employed people with disabilities	

American Indians and Alaska Natives: Per federal law, American Indians enrolled with a federally recognized tribe, children and grandchildren of American Indians enrolled with a federally recognized tribe and certain Alaska Natives do not have to pay a premium. To get AHCCCS Medical Assistance at no cost, you must give us proof of tribal enrollment.	
Co-payments	
A co-payment is the amount you pay a health care provider when you receive a medical service. Your co-payment amount will vary depending on which AHCCCS program you are enrolled in and the services you need. For some AHCCCS programs, the provider can deny services if the co-payments are not made. Co-payments for services are:	
•	$2.30 to $10.00 for prescriptions	
•	$0 to $30.00 for non-emergency use of an emergency room	
•	$2.30 to $3.00 for physical, occupational or speech therapy	
•	$3.40 to $5.00 for outpatient visits for evaluation and management services including doctor’s office visits	
Remember to report any changes in income because this may change your co-payment amount.	
The following people are never asked to pay co-payments:	
•	Children under age 19.	
•	Individuals up through age 20 eligible to receive services from the Children’s Rehabilitative Services (CRS) program.
•	People who receive hospice care.	
•	People determined to be Seriously Mentally Ill (SMI) by the Arizona Department of Health Services.	
•	American Indian members who are active or previous users of the Indian Health Service, tribal health programs operated under Public Law 93-638 or urban Indian health programs.	
•	People who are acute care members and who are residing in nursing homes or residential facilities such as an Assisted Living Home and only when the acute care member’s medical condition would otherwise require hospitalization. The exemption from copayments for acute care members is limited to 90 days per contract year.	
In addition, co-payments are never charged for the following services for anyone:	
•	Hospitalizations	
•	Emergency services	
•	Family planning services and supplies	
•	Services paid for on a fee-for-service basis	
•	Pregnancy-related health care including tobacco cessation treatment for pregnant women
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How does AHCCCS Medical Assistance work?	
If you are approved for AHCCCS Medical Assistance, you will receive your health care from an AHCCCS Complete Care (ACC) plan unless:	
•	You are American Indian and you choose American Indian Health Program as your health plan.	
•	You are approved for one of the Medicare Savings Programs.	
•	AHCCCS can only pay for your emergency services because of your status with United States Citizenship and Immigration Services. If you are approved for emergency services only, you may receive medical services from any provider (doctor, hospital, etc.) that has an agreement to bill AHCCCS for covered emergency services.	
How does a health plan work?	
•	The health plan works with health care providers (doctors, hospitals, pharmacies, etc.) to provide all AHCCCS covered services.	
•	The health plan will send you a member handbook once you are enrolled.	
•	You can call the health plan if you have any questions about your benefits or services or if you need an accommodation because of a disability or interpreter services. The phone number for your health plan’s member or customer services can be found on your AHCCCS ID Card and in your Member Handbook.	
How can I get behavioral health services?	
•	You can go through your primary doctor, or	
•	Call the behavioral health telephone number on your AHCCCS ID Card.
What if I have Medicare or other health insurance?	
•	Be sure to tell your health plan that you have Medicare or any other health insurance.	
•	If your doctor does not contract with your AHCCCS Complete Care (ACC) plan, your doctor must call the ACC plan to coordinate care or you may be responsible for any Medicare or other health insurance co-payments or deductibles.	
•	If you are in an HMO, you should pick a primary doctor who works with both your HMO and your ACC plan.	
•	If you have Medicare, your prescription coverage under AHCCCS is limited. If you have questions about prescriptions, call 1-800-MEDICARE (633-4227), or your AACC plan.	
What do primary doctors and specialists do?	
Once enrolled, you will get a list of primary doctors in your area from the health plan. You must choose your primary doctor or one will be assigned to you. You have the right to change your primary doctor at any time by calling your health plan’s member or customer services. Your primary doctor will:	
•	Take care of your health care.	
•	Be responsible for authorizing your non-emergency medical services.	
•	Be the first person you go to for non-emergency medical care.	
•	Send you to a specialist when needed.
Additional information for veterans and spouses of veterans may be provided by:
•	https://www.beconnectedaz.org/
•	Arizona Department of Veterans Services (ADVS) https://dvs.az.gov/

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Who Can Complete an Application?
This application may be completed by you or anyone you choose who knows or can get the information needed to complete the application for you and your family members. The terms “customer” and “you” on this form refer to the person applying for AHCCCS Medical Assistance and/or Medicare Savings Program benefits. You and your spouse can use the same application form to apply. If you have a conservator or guardian, your conservator or guardian must complete this form for you.

Instructions to the Customers
Check Yes or No on the application form when asked if you are applying for AHCCCS Medical Assistance or for help to pay Medicare costs. You can check Yes to either question or to both.
•	Answer all questions on pages 1 through 6 for each person applying.
•	If you need more room, attach additional sheets of paper to provide all requested details.
•	Read page E for an explanation of your rights and responsibilities and providing a social security number.
•	Sign the application.
•	Attach all requested verification when you send your application.
•	Keep pages A, B, C, D, E, F, and G for your records and mail pages 1 through 6 to the MA-SP Office:

AHCCCS Medical Assistance
Specialty Programs (MA-SP)
801 E Jefferson St
Phoenix AZ 85034
 FAX: (602) 258-4619
		•	If you are applying for AHCCCS Medical Assistance, read page G and choose an AHCCCS Complete Care (ACC) plan.
•	If you have any questions regarding these programs, or need help filling out the application, please call: 
•	If you are calling from area codes (480, 602 or 623) dial (602) 417-5010 and choose option 5. 
•	If calling from area codes (520, 760 or 928) dial toll free 1-800-528-0142.

After we receive your application, we will either contact you for additional information or, if your application is complete, make a decision about whether you qualify. We will send you a notice explaining the decision.	

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Rights and Responsibilities of Customers	

You have the right to:
1.	Be treated fairly and equally regardless of race, religion, national origin, sex, age, disability, or political beliefs.
2.	To apply for AHCCCS Medical Benefits and to be given a notice that tells you if you are eligible or not.
3.	Review AHCCCS manuals that show the rules and regulations of the AHCCCS program if you want to know the reason why your application is denied.
4.	Have all information you give regarding your eligibility kept private according to state and federal law.
5.	A fair hearing if you disagree with an adverse action taken by the AHCCCS Administration. Adverse action means your application for AHCCCS services was denied, your AHCCCS benefits were ended or your AHCCCS services were reduced. You may also request a hearing if a decision is not made on your application within 45 days and the delay is due to AHCCCS. Your hearing will be conducted by an Administrative Law Judge and a decision will be issued by the AHCCCS Director. You have the right to review your case record before the hearing. You have the right to represent yourself or to have someone else represent you. If you wish to ask for a hearing, your request must be in writing and mailed or delivered to the Office of the General Counsel, 801 East Jefferson St., PO Box 25520, MD 6200, Phoenix, Arizona 85034 or faxed to 602-253-9115.

You have the responsibility to:
1.	Provide AHCCCS with the needed information to correctly determine your eligibility and authorize AHCCCS to investigate and contact any sources necessary to confirm the accuracy of the information which pertains to eligibility.
2.	To report payments going in or out of your trust, if you have one.

If you are eligible you must:
1.	Notify the AHCCCS/ALTCS office as soon as possible but no later than within 10 days by phone, letter or in person, whenever there are any changes in your income, address, marital status, Medicare coverage, household composition, or other circumstances which could affect your eligibility.
2.	Cooperate with Arizona or Federal personnel in the completion of a quality control review of your eligibility.

Providing Social Security Numbers and Immigration Status	

You must provide or apply for a Social Security number (SSN) for every applicant. Immigrants who are not legally able to obtain an SSN are not required to provide one. This is required under the Social Security Act (SSA) of 1935 (Section 1137) as amended by P.L. 98-369. Providing a Social Security number for someone who is not applying is optional. We will not use your SSN as your AHCCCS identification number. Your SSN will be used to check the identity of those receiving assistance, to prevent double payments, to determine benefits available under other programs, to verify state residency or other conditions of eligibility, and to make mass annual changes more easily. Your SSN will be used in computer matching available through the State Income and Eligibility Verification System (IEVS) to obtain wage, income and other information from: (a) the IRS, (b) the Social Security Administration, (c) Arizona Department of Economic Security, and (d) other states administering TANF, Medicaid, Unemployment Insurance, Food Stamps, Programs under Title I, X, XIV, XVI of the SSA and other state wage information collection agencies. AHCCCS will use the 
information available from this computer matching to verify income and whether you have Medicare. When the information you give is questionable, AHCCCS will verify the information by contacting other sources.

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Assignment Of Rights To Other Benefits For Medical Care
(Applicable only to AHCCCS Medical Assistance and the Qualified Medicare Beneficiary Program)	
I understand that if I am or members of my family are approved for AHCCCS benefits, AHCCCS can collect payment from any other parties who may be responsible for paying for our health care costs. This includes:
•	Private or employer-sponsored health insurance (not including Medicare)
•	Persons, such as an absent spouse or parent, who are legally responsible for providing medical support
•	Private or employer-sponsored disability insurance
•	Private or employer-sponsored accident insurance
•	Insurance claims, jury awards, or legal settlements resulting from injuries
I understand that AHCCCS cannot collect more than the costs paid by AHCCCS. I also understand that I must give information about other responsible parties and take any action needed to receive medical support. 

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How to choose a health plan		
You need to choose an AHCCCS Complete Care (ACC) health plan that serves your county. 		
•	All ACC plans provide the same covered medical services. 
•	Before choosing an ACC plan, check with your doctor, pharmacy or hospital to see if they work with the ACC plan that you want. If you want more information about the doctors, specialists or hospitals that work with an ACC plan that serves your county, call the number listed below for the ACC plan or visit the ACC plan’s website.
•	American Indian members may choose from American Indian Health Program or an ACC plan.
•	If you do not choose an ACC plan, one will be assigned to you. 
•	If you have been enrolled in an ACC plan within the past 90 days, you may be enrolled with your previous ACC plan. 
•	If you need help selecting an ACC plan you may speak to a Benefits and Eligibility Specialists by calling (602) 417-7100 from area codes (480), (602), and (623) or 1-(800)-334-5283 from area codes (520) and (928).		

Geographic Service Area (GSA)	Available AHCCCS Complete Care (ACC) Health Plans	
North
•	Apache
•	Coconino 
•	Mohave	
•	Navajo
•	Yavapai	•	American Indian Health Program
•	Arizona Complete Health - Complete Care Plan
•	Health Choice Arizona 	
Central
•	Maricopa
•	Gila 
•	Pinal, excluding ZIP codes 85542, 85192, and 85550	
	•	American Indian Health Program
•	Arizona Complete Health - Complete Care Plan
•	Banner-University Family Care
•	Molina Complete Care
•	Mercy Care
•	Health Choice Arizona 
•	UnitedHealthcare Community Plan	
South
•	Cochise
•	Graham
•	Greenlee
•	La Paz
•	Pima	
•	Santa Cruz
•	Yuma
•	ZIP codes 85542, 85192, and 85550	•	American Indian Health Program
•	Arizona Complete Health - Complete Care Plan
•	Banner-University Family Care
•	UnitedHealthcare Community Plan (Pima County Only)	
Health Plan Name	Phone Number	Website	
American Indian Health Program	Maricopa County: 
(602) 417-7100
All other counties: 
1-800-334-5283	www.azahcccs.gov/AmericanIndians/AIHP/	
Arizona Complete Health - Complete Care Plan	1-888-788-4408	www.azcompletehealth.com/completecare	
Banner-University Family Care	1-800-582-8686	www.bannerufc.com/acc	
Molina Complete Care	1-800-424-5891	www.mccofaz.com	
Mercy Care	1-800-624-3879	www.mercycareaz.org	
Health Choice Arizona 	1-800-322-8670	www.healthchoiceaz.com	
UnitedHealthcare Community Plan	1-800-348-4058	www.uhccommunityplan.com	

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AHCCCS Application Form	

Instructions: To start the application process, you can call us at 800-528-0142 (toll-free). You may also complete this form and return it by using one of the methods on page D. Missing or incomplete information may cause a delay in the processing of your application.	

Are you applying for AHCCCS Health Insurance?	Yes		No
Are you applying for help to pay Medicare costs?			Yes		No	
Customer Information	
Customer’s Legal Name (First, MI, Last, Suffix):
     
	Social Security Number:
     	
Date of Birth:
     	Male	Female	Medicare Claim Number:
     	
Are you a U.S. Citizen?

Yes, a U.S. citizen
No, not a U.S. citizen
If no, what number is on your immigration card? 
A               
	What is your immigration status?
Lawful Permanent Resident (LPR)Asylee
Refugee
American Indian Born in Canada
Cuban-Haitian Entrant
Hmong or Laotian Highlander
Victim of Trafficking
Afghan/Iraqi Special Immigrant
Battered noncitizen
Conditional Entrant	
Deportation Withheld
Indefinite Detainee
Parolee for at Least One Year 
Citizen of Republic of the Marshall Islands
Citizen of Federated States of Micronesia
Citizen of Republic of Palau
Other:
                         	
Home Address:
     	City:
     	State:
     	ZIP Code:
     	
Mailing Address (if different):
     	City:
     	State:
     	ZIP Code:
     	
Home Phone Number:
     	Work Phone Number:
     	Message Number:
     	E-mail Address:
     	
What language do you speak?	English		Spanish	Other                               
What language do you read?		English		Spanish	Other                               	
Ethnic Group - Optional (will not affect eligibility)	Hispanic		Non-Hispanic Latino	
Race (Select one or more) (Optional)		White						Asian													American Indian
Black/African American						Hawaiian or other Pacific Islander						Alaska Native 	
Check your current Marital Status:	
Never Married			Married			Divorced	
Common-Law			Widowed	Effective Date of Current Marital Status:
     	
If married, do you and your spouse live together? Yes		No	If No, date of separation:           	
Did anyone you are applying for receive medical services in the last three months and need help with these expenses? Yes		No If so, who?                                              
What months?                     			                    			                    
Is the person needing help with medical expenses pregnant or had a pregnancy end in the last 5 months? 
Yes			No

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Accommodations for Printed Letters	
Does the customer, authorized representative, or legal guardian have a visual impairment that requires an alternative format for printed letters? 
No	Yes   If yes, who needs the accommodation:                                         

If yes, what kind of alternative format do you need? Please choose one option:
Letters in HEAplus account (note: this person must have an HEAplus account)
Readable PDF sent by secure email
Large print: larger print letters sent by U.S. mail will be provided Arial 24-point font.
Other:                                                                       	

Authorized Representative	
If you want to allow someone else to represent you or you have a legal guardian, provide the information below. 	
Representative’s Name:                                              
Is the representative acting on behalf of an organization? Yes	No
Organization’s Name:                                              
Is the representative your legal guardian? Yes	No
Representative’s Date of Birth (optional):                         
Representative’s Mailing 	Address:                                                        
				City:                          State:       ZIP Code:           
Representative’s Phone Number:                                         
What is the representative’s preferred language to speak? 
English		Spanish	Other:                                                   
What is the representative’s preferred language to read?
English		Spanish	Other:                                                   
	
My representative would like to get information about this application by:
E-mail:	Yes		No E-mail address:                                              
Text:			Yes 	No Number to text (standard text rates apply):                     
If ‘Yes’ is not marked for E-mail or Text, all information for this application will be sent via U.S. Mail to the mailing address provided.	

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By signing below, I, the customer, give permission for the person listed above as my representative to act on my behalf in the process of qualifying me for AHCCCS Medical Assistance, help with Medicare costs, Nutrition Assistance, Cash Assistance, and/or Tuberculosis Control. I, therefore:
•	Give permission for my representative to complete and sign my application.
•	Give permission for my representative to provide any documents requested, including personal information.
•	Give permission to my representative to sign on my behalf to permit other people, businesses, or agencies to give personal information about me to DES and/or AHCCCS, including protected health information needed to determine if I am disabled. 
•	Agree to give information about my personal circumstances to my representative.
•	Agree to allow my representative to assign all my rights to medical reimbursement claims to AHCCCS on my behalf.	By signing below, I, the representative, agree to act on the customer’s behalf. I also agree to:
•	Maintain the confidentiality of any information regarding the customer or beneficiary provided by the agency.
•	Provide only truthful and complete information under penalty of perjury.
•	Fill in and sign needed forms.
•	Obtain and give to DES and/or AHCCCS all information needed to determine if the customer can qualify for help with healthcare costs, help with Medicare costs, Nutrition Assistance, Cash Assistance, and/or Tuberculosis Control, such as the customer’s Social Security number, income, assets, citizenship, residency, medical insurance, and information about the customer’s spouse, minor children, and parents (if the customer is a minor child). The requirement to cooperate with DCSS in establishing the identity of a child’s parents and in obtaining medical support is suspended under a temporary waiver from 09/01/2023 through 06/30/2025. 
•	Tell DES and/or AHCCCS right away if the customer:
o	Has an increase or decrease in income;
o	Has an increase or decrease in assets;
o	Changes ownership of assets, including opening or closing financial accounts;
o	Has a change in address; or
o	Has a change in health insurance or the amount of premiums paid.	
If I am determined eligible, this authorization will stay in effect until I or my representative tells you to stop it. This authorization will expire when my application for assistance is withdrawn or denied, or when my eligibility ends. However, this authorization will continue during any time while I am contesting my eligibility in an administrative hearing or court proceeding.	
PRINTED NAME OF CUSTOMER
     
	PRINTED NAME OF REPRESENTATIVE
     	
SIGNATURE OF CUSTOMER
     
	DATE
     	SIGNATURE OF REPRESENTATIVE
     	DATE
     
	
PRINTED NAME OF WITNESS (if customer signed with a mark)
     	PRINTED NAME OF REPRESENTATIVE ORGANIZATION (when applicable)
     	

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Spouse’s Information, If living together	
Spouse’s Legal Name (First, MI, Last, Suffix):
     	Spouse’s Date of Birth:
     	Spouse’s Social Security Number (optional if not applying):
     	
Is your spouse applying for AHCCCS Medical Assistance?		Yes		No
Is your spouse applying for help to pay Medicare Costs?			Yes		 No
Does your spouse need help paying for medical bills					  	Yes		No
from the last three months?
What months?                                               	If applying, Spouse’s Medicare Claim Number:
                    	
If applying, Ethnic Group of Spouse (Optional):	Hispanic		Non-Hispanic Latino	
If applying, Race of Spouse (Select one or more) (Optional)
White							Asian					American Indian				Black/ African American	
Alaska Native		Hawaiian or other Pacific Islander	
If applying, is your spouse a U.S. Citizen?

Yes, a U.S. citizen
No, not a U.S. citizen
If no, what number is on your immigration card? A                         
	What is your spouse’s immigration status?
Lawful Permanent Resident (LPR)	
Asylee
Refugee
American Indian Born in Canada
Cuban-Haitian Entrant
Hmong or Laotian Highlander
Victim of Trafficking
Afghan/Iraqi Special Immigrant
Battered noncitizen
Conditional Entrant
	
Deportation Withheld
Indefinite Detainee
Parolee for at Least One Year 
Citizen of Republic of the Marshall Islands
Citizen of Federated States of Micronesia
Citizen of Republic of Palau
Other:
                    	
Dependent Children Information	
Do you have any unmarried children living with you who are under age 18 or under age 22 and a student?

If YES, list below. If you need more space, attach a separate piece of paper with the information requested.	Yes		No	
Child’s Legal Full Name
(Last, First)	Child’s Date of Birth	Child’s Social Security Number (optional)	Type of School, if Student	
     	     	     	     	
     	     	     	     	
Non-Financial Information	Customer	Spouse 
(if applying)	
1.	Do you live in Arizona? 	Yes		No	Yes		No	
2.	Do you receive Medicare Part A?	Yes		No	Yes		No	
3.	Do you receive Medicare Part B?	Yes		No	Yes		No	
4.	Have you been determined blind or disabled by the Social Security Administration?	Yes		No	Yes		No	
5.	If you answered NO to number 4 and you are under age 65, do you have a disability that has kept or will keep you from working for at least 12 months?	Yes		No	Yes		No	
6.	Are you a person under age 65 who has lost Title II Social Security Disability benefits because of earnings?	Yes		No	Yes		No	
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Income	
Do you, your spouse, or your dependent children receive or expect to receive any of the following types of income? Check Yes or No for each item.	
Yes		No	Employment Income	Yes		No	Veteran’s Benefits	Yes	No	Rental Income	
Yes		No	Self Employment Income	Yes		No	Annuity Income	Yes	No	Mortgage/
Contract Payments	
Yes		No	Social Security Benefits	Yes		No	Winnings (Lottery/Gambling)	Yes	No	Child Support/
Alimony	
Yes		No	Interest on financial accounts	Yes		No	Gifts/loans/
contributions	Yes	No	BIA/Tribal Assistance	
Yes		No	Royalties/Dividends	Yes		No	Disability Insurance	Yes	No	Payments from a trust	
Yes		No	Cash Assistance	Yes		No	Unemployment Insurance	Yes	No	Tips or Commissions	
Yes		No	Pensions	Yes		No	Student Grants/ Scholarships/Loans	Yes	No	Earned Income Tax Credit (EITC)	
Yes		No	Railroad Retirement	Yes		No	Payments for Room/Board	Yes	No	Other:     	
For each item marked Yes, provide all of the information requested below. If you need more room, attach a separate piece of paper containing the requested information. Send current verification of all income listed (for example, check stubs, award letters, the most recent income tax forms, if self employed). Copies are acceptable.	
Name of Person Receiving the Income	Type of Income	Date received or expected to be received	Gross Amount 
(before deductions)	How often received? (weekly, bi-weekly, etc.)	
     	     	     	     	     	
     	     	     	     	     	
     	     	     	     	     	
Has there been a change in any of your income during the last three months or do you expect a change in income? 
	If Yes, complete below. If you need more room, attach a separate piece of paper with the information requested.	Yes		No	
Date of change or expected change:
     
	Type of income affected:
     	What is the change?
     	

DE-103 (rev 03/2025)																																														Page 5	
 Medical Coverage	
Do you or your spouse have medical insurance coverage, other than Medicare?

		If Yes, complete the information below and send a copy of the 
		Insurance ID card.	Yes		No	
Name of Insurance Company	Who is covered by Insurance?	
     	     	
     	     	
Do you or your spouse have an injury or illness resulting from an accident (pedestrian, automobile, or other vehicle, on the job, etc.)?
		If Yes, complete the items below:	Yes		No	
Name	Type of Injury	Date of Injury	Name and Address of Insurance or Company Responsible for Medical
Costs due to the Injury	
     	     	     	     	
If eligible for AHCCCS Medical Assistance or QMB, by signing this application, I agree to assign to AHCCCS all rights to third party payments of medical expenses, including insurance coverage, to the extent that costs are paid by AHCCCS.	
Health Plan Choice	
If you are applying for AHCCCS Medical Assistance, choose an AHCCCS Complete Care (ACC) plan that serves your county. See page G or a list of health plans.	
Name of AHCCCS Complete Care (ACC) plan you choose (from page G):
     	

	
DE-103 (rev 03/2025)																																																	Page 6

Your Opportunity To Register To Vote	
If you are not registered to vote where you live now, would you like to apply to register to vote here today? 
 
Applying to register or declining to register to vote will not affect the amount of assistance that you will be provided by this agency.

Yes		No

IF YOU DO NOT CHECK EITHER BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO REGISTER TO VOTE AT THIS TIME.
 
If you would like help in filling out the voter registration application form, we will help you. The decision whether to seek or accept help is yours. You may fill out the application form in private.
 
If you believe that someone has interfered with your right to register or to decline to register to vote, your right to privacy in deciding whether to register or in applying to register to vote, or your right to choose your own political party or other political preference, you may file a complaint with the State Election Director, Secretary of State’s Office, 1700 West Washington, Phoenix, AZ 85007, 602-542-8683.
 
You may also get a voter registration form at https://azsos.gov/elections
 	
Penalty Warning	
The information provided on this form may be verified by federal, state, and local officials. If anything is inaccurate, you may be denied benefits.
1.	You must not knowingly withhold or give false information with the intent to receive or to continue receiving AHCCCS benefits to which you are not entitled.
2.	You will be required to pay back to AHCCCS any benefits you receive as a result of withholding or giving false information and you will be subject to criminal prosecution.

It is fraud for any person to knowingly withhold information with the intent to receive or continue to receive benefits to which he/she is not eligible. Any person found guilty of fraud may be subject to fines, criminal prosecution, imprisonment or other penalties as provided for by applicable State and Federal laws.	
Release Of Information	
I authorize AHCCCS to investigate and contact any sources necessary to establish eligibility and the accuracy of financial information that pertains to AHCCCS eligibility.	
Statement Of Truth	
I affirm under penalty of perjury that I have read and understand all the information on this application, and the statements are true and correct to the best of my knowledge. I affirm that the citizenship/immigration status is correct for each person applying. I do not have to give the citizenship or immigration status of persons who are not applying for healthcare benefits. I affirm that any photocopies I have provided are the same as the original.	
SIGNATURE OF CUSTOMER
     	DATE
     	SIGNATURE OF WITNESS (if customer signed with a mark)
     	DATE
     	
SIGNATURE OF SPOUSE
     	DATE
     	SIGNATURE OF REPRESENTATIVE
     	DATE
     	

DE-103 (rev 03/2025)																																															Page 7

NOTICE OF NON-DISCRIMINATION
The Arizona Health Care Cost Containment System (AHCCCS) complies with applicable Federal civil rights laws and does not exclude, discriminate, or treat individuals differently on the basis of race, color, national origin (including limited English proficiency and primary language), age, disability, or sex (including pregnancy, sexual orientation, gender identity, and sex characteristics). AHCCCS provides free aids and services to people with disabilities to communicate effectively with us, such as qualified sign language interpreters and written information in other formats (large print, audio, accessible electronic formats, and other formats). AHCCCS provides free language services to people whose primary language is not English, such as qualified interpreters and information written in other languages. If you need these services, contact the Health-e-Arizona Plus Customer Support Center at 1-855-432-7587 (TTY: 711).

If you believe that AHCCCS failed to provide these services or discriminated in another way on the basis of race, color, national origin, age, disability, or sex, you can file a grievance with the agency's Section 1557 Coordinator in the AHCCCS Office of the General Counsel. You can file a grievance in person or by mail, fax, or email. Your grievance must be in writing and must be submitted within 180 days of the date that the person filing the grievance becomes aware of what is believed to be discrimination. Submit your grievance to: Office of the General Counsel, MD 6200, 801 E. Jefferson, Phoenix, AZ 85034. Phone: 602-417-4455, Fax: 602-253-9115 Email: EqualAccess@azahcccs.gov. You can find this information on our website: https://www.azahcccs.gov/Members/GetCovered/RightsAndResponsibilities/nondiscrimination.html. You can also file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/ocr/smartscreen/main.jsf, or by mail at U.S. Department of Health and Human Services; 200 Independence Avenue, SW; Room 509F, HHH Building; Washington, D.C. 20201; or by phone: (202) 368-1019 or toll free 800-368-1019, 800-537-7697 (TTY). Complaint forms are available at https://www.hhs.gov/civil-rights/filing-a-complaint/complaint-process/index.html.

Aviso de No Discriminación 
Arizona Health Care Cost Containment System (AHCCCS) cumple con las leyes federales de derechos civiles y no excluye, discrimina o trata a los individuos de manera diferente en base a la raza, color, origen nacional (incluyendo dominio limitado del inglés y idioma primario), edad, discapacidad o sexo (incluyendo embarazo, orientación sexual, identidad de género y características sexuales). AHCCCS proporciona asistencia y servicios gratuitos a las personas con discapacidades para que se comuniquen de manera eficaz con nosotros, como los siguientes intérpretes de lenguaje de señas capacitados y información escrita en otros formatos (letra grande, audio, formatos electrónicos accesibles, y otros formatos). AHCCCS proporciona servicios lingüísticos gratuitos a personas cuya lengua materna no es el inglés, como los siguientes intérpretes capacitados y información escrita en otros idiomas. Si necesita recibir estos servicios, comuníquese con Health-e-Arizona Plus Customer Support Center at 1-855-432-7587 (TTY: 711). Si considera que AHCCCS no le proporcionó estos servicios o lo discriminó de otra manera por motivos de origen étnico, color, nacionalidad, edad, discapacidad o sexo, puede presentar un reclamo a Coordinador de la Sección agencia 1557 de la AHCCCS Office of the General Counsel. Puede presentar el reclamo en persona, por correo postal, fax o correo electrónico. Su queja deberá presentarse por escrito en plazo de 180 días a partir de la fecha en la que la persona que se queja se percate de lo que le parezca ser discrimen. Remita su queja a: Office of the General Counsel, MD6200, 801 E. Jefferson, Phoenix, AZ 85034. Número de teléfono: 602-417-4455, o envíela por fax a: 602-253-9115. Envíela por correo electrónico (Email) a: EqualAccess@azahcccs.gov. Usted puede encontrar esta informacion en nuestro sitio web: https://www.azahcccs.gov/Members/GetCovered/RightsAndResponsibilities/nondiscrimination.html. También puede presentar un reclamo de derechos civiles ante la Office for Civil Rights (Oficina de Derechos Civiles) del Department of Health and Human Services (Departamento de Salud y Servicios Humanos) de EE. UU. de manera electrónica a través de Office for Civil Rights Complaint Portal, disponible en https://ocrportal.hhs.gov/ocr/portal/ lobby.jsf, o bien, por correo postal a la siguiente dirección o por teléfono a los números que figuran a continuación: U.S. Department of Health and Human Services; 200 Independence Avenue, SW; Room 509F, HHH Building; Washington, D.C. 20201; 1-800-368-1019, 800-537-7697 (TDD). Puede obtener los formularios de reclamo en el sitio web http://www.hhs.gov/ocr/office/file/index.html.

English	If you speak English, language assistance services, free of charge, are available to you. Call 1-855-432-7587 (TTY: 711).		
Spanish	ATENCIÓN: si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística. Llame al 1-855-432-7587 (TTY: 711).		
Navajo	Díí baa akó n­ín­ízin: Díí saad bee yán­ílti'go Diné Bizaad, saad bee áká`ánída`áwo`dḝḝ`, táá jiik'eh, éí ná hólộ, kojị' hódíílnih 1-855-432-7587 (TTY: 711)		
Apache	Ndéé k'ehgo yánłt'i'yúgo Ndéé biyát'į'híí bee kich'į' ódiihíí beegozáá áłdó' do hát'íí ileegoda. Náh inlk'id ánt'iiyúgo béésh bich'i' nłltsogyúgo díí bik'ehgo bil ónlchííd 1-855-432-7587 (TTY: 711)		
Chinese	注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-855-432-7587（TTY： 711）		
Vietnamese	CHÚ Ý: Nếu bạn nói Tiếng Việt, có các dịch vụ hỗ trợ ngôn ngữ miễn phí dành cho bạn. Gọi số 1-855-432-7587 (TTY:711).		
Arabic	ملحوظة:  إذا كنت تتحدث العربية، فإن خدمات المساعدة اللغوية تتوافر لك بالمجان.  اتصل برقم 1-885-432-7587 (رقم هاتف الصم والبكم:711).		
Tagalog	PAUNAWA: Kung nagsasalita ka ng Tagalog, maaari kang gumamit ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-855-432-7587 (TTY:711).		
Korean	주의: 한국어를 사용하시는 경우, 언어 지원 서비스를 무료로 이용하실 수 있습니다. 1-
855- 432-7587 (TTY: 711) 번으로 전화해 주십시오.		
French	ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-855-432-7587 (ATS : 711).		
German	ACHTUNG: Wenn Sie Deutsch sprechen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-855-432-7587 (TTY: 711).		
Russian	ВНИМАНИЕ: Если вы говорите на русском языке, то вам доступны бесплатные услуги перевода. Звоните 1-855-432-7587 (телетайп: 711).		
Japanese	注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。1-855- 432- 7587（TTY: 711）まで、お電話にてご連絡ください		
Serbo- Croatian/ Croatian	OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezičke pomoći dostupne su vam besplatno. Nazovite 1-855-432-7587 (TTY- Telefon za osobe sa oštećenim govorom ili sluhom: 711). 		
Syriac/
Assyrian	ܙܘܼܗܵܪܵܐ: ܐܹܢ ܐܲܚܬܘܿܢ ܟܹܐ ܗܲܡܙܸܡܝܼܬܘܿܢ ܠܸܫܵܢܵܐ ܐܵܬܘܿܪܵܝܵܐ، ܡܵܨܝܼܬܘܿܢ ܕܩܲܒܠܝܼܬܘܿܢ ܚܸܠܡܲܬܹܐ ܕܗܲܝܲܪܬܵܐ ܒܠܸܫܵܢܵܐ ܡܲܓܵܢܵܐܝܼܬ. ܩܪܘܿܢ ܥܲܠ ܡܸܢܝܵܢܵܐ 711 1-855-432-7587 (TTY: )).		
Persian/ Farsi	
		
Thai	เรียน: ถ้าคณพดภาษาไทยคณสามารถใช้บริการช่วยเหลือทางภาษาได้ฟรี โทร 1-855-432-7587 (TTY:711).