Apply for AHCCCS Medical Assistance/KidsCare

If you are waiting for your application to be processed or you are not eligible for AHCCCS medical assistance, you may qualify to receive drug and alcohol and mental health treatment services through other funding sources administered by the Regional Behavioral Health Authority (RBHA). For more information, contact the RBHA in your area: Central Arizona at 800-564-5465; Northern Arizona at 800-322-8670; Southern Arizona at 866-495-6738.

Apply Online

You can apply online for AHCCCS Medical Assistance, Nutrition Assistance, and Cash Assistance using Health-e-Arizona Plus (HEAplus). You can apply for yourself, your family, or someone close to you.

You may be able to reduce office visits and postage delays by using Health-e-Arizona Plus.

Note: Health-e-Arizona Plus is offered in both English and Spanish.

Print an Application

Click on the link to DES below if you (or the person you are applying for) are one or more of the following:

• An adult without children
• A pregnant woman
• A family with children
• A child only

You can use one application to apply for AHCCCS Medical Assistance for everyone in your household. Applications for AHCCCS Health Insurance are available on the Department of Economic Security (DES) Application page:

• Application for Benefits
• Aplicación de Beneficios

Click on the link to the application below if you (or the person you are applying for) are one or more of the following:

• 65 years of age or older
• An individual who is blind or disabled
• A working individual with a disability (Freedom to Work)
• An individual that wants help with Medicare costs only

The application below is to apply for AHCCCS Health Insurance and/or Medicare Costs Sharing programs. To open the form so you can print it, click on the link below.

• Medicare Cost Sharing and AHCCCS Health Insurance Application - DE-103
• Solicitud para Gastos Compartidos de Medicare y Seguro de Salud de AHCCCS - DE-103

Note: This application process does not apply for individuals who are in need of Arizona Long Term Care System (ALTCS) services, such as in home healthcare, nursing facility, or assisted living. To apply for Long Term Care, see below.

How to Apply for Arizona Long Term Care (ALTCS)

The Arizona Long Term Care System (ALTCS) program is for individuals who are 65 or older, blind, or disabled and need ongoing services at a nursing facility level of care.

However, program participants do not have to reside in a nursing home. Many ALTCS participants live in their own homes or an assisted living facility and receive needed in-home services.

To apply for Long Term Care, call or visit an Arizona Long Term Care office.

• Filing an Application for the Arizona Long Term Care System (ALTCS) - DE-828 | Rich Text Format
• Llenando una Solicitud para el Sistema de Cuidados a Largo Plazo de Arizona (ALTCS) - DE-828 | Rich Text Format
• Request For Application for Arizona Long Term Care Services - DE-101 and DE 202 | Rich Text Format
• Petición Para Solicitud de Servicios AHCCCS Long Term Care - DE-101SP and DE 202SP | Rich Text Format
• Authorized Representative Form - DE-112 | Rich Text Format
• Documento De Representante Autorizado - DE-112 | Rich Text Format
• Authorization to disclose protected health information to AHCCCS - DE-202 (with cover page)
• Autorizacion para revelar a AHCCCS informacion protegida acera de su salad - DE-202SP (with cover page)
• Authorization to disclose protected health information to AHCCCS - DE-202 Large Print (with cover page) | Rich Text Format
• Autorizacion para revelar a AHCCCS informacion protegida acera de su salad - DE-202SP Large Print (with cover page) | Rich Text Format