Youth in Tribal Foster Care Update

A. Update Information	
Out of home placement	Change in out of home placement Returned home	Adopted
Date placed out of home, placement changed, returned home, or adopted:	
B. Child(ren)’s Information (Please print clearly)	
Name:	Date of Birth:	Male	Female	
Social Security Number:	Tribal Affiliation:	
Name:	Date of Birth:	Male	Female	
Social Security Number:	Tribal Affiliation:	
Name:	Date of Birth:	Male	Female	
Social Security Number:	Tribal Affiliation:	
Name:	Date of Birth:	Male	Female	
Social Security Number:	Tribal Affiliation:	
C. Placement Information (Please print clearly)	
Placed with:	
Relationship to child:	Phone:	
Address:	
City:	State:	Zip Code:	
D. Tribal Social Services/Foster Care Information (Please print clearly)	
Tribe:	Social Worker Name:	
Address:	
City:	State:	Zip Code:	
Phone #:	Email:	
Submitted by:	Date:	

MA-436 (rev 01/2023)	Page 1 of 2

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.

Instructions for filling out the form:
Section A:
Question 1 – Check one of the four boxes to indicate the updated placement. Question 2 – Enter the date the change occurred.
Section B:
Enter the child(ren)’s identifying information in each field.
NOTE: If multiple siblings are placed together, only one form is needed. If one or more siblings are placed separately, complete a separate form for each placement. (Example: Three siblings are removed from their home. Two of them are placed with one foster family, and the third child is placed with another. Two forms would be needed; one with the two siblings, and the other with the third).
Section C:
Enter the information for the child’s new placement.
NOTE: “Placed with” field: Enter the name of the child(ren)’s primary contact at the new placement. This may be a staff contact at a group home, a foster parent or the child’s parent/guardian when returned home.
Section D:
Enter the identifying information for the Tribal Social Services/Foster Care agency and the child’s social worker. It is important to include a contact number and address as the DES or AHCCCS eligibility worker may need more information. For children in the custody of Tribal Social Services, notices about eligibility and renewals will be sent to the child’s social worker at the address provided.

Submitting the form
When the child has current AHCCCS eligibility the form can be submitted in any of the following ways:
For a child who does NOT have ALTCS, send the completed form to a local DES office. A list of DES offices can be found at https://des.az.gov/find-your-local-office;
For a child who has ALTCS, send the form to a local ALTCS office. A list of ALTCS offices and their contact information can be found at https://www.azahcccs.gov/Members/ALTCSlocations.html; or
Email the completed form to Interagencyliasion@azahcccs.gov along with details about the child’s current enrollment.
Please include a copy of the Tribal Court Order of Placement if available (only needed for the initial out-of-home placement).
When the child does not have current AHCCCS eligibility:
Complete this form and submit it with a completed AHCCCS application to the local DES office, or online through HEAplus; or
Email the completed form to Interagencyliasion@azahcccs.gov.

MA-436 (rev 01/2023)	Page 2 of 2