DE-101/DE-202: Arizona ALTCS Request for Application

Enter the Customer's Legal Name (First, Middle Initial, Last, Suffix), Customer's Date of Birth and Customer's Social Security Number, and mark Male or Female.

Applying and providing information is voluntary, but some information is required to make a determination. For example, you must provide or apply for a Social Security number for every applicant. (Immigrants who are not legally able to obtain a Social Security number are not required to provide one.) Therefore, if personal information is not provided, you may not be eligible for benefits.

Under Marital Status, mark Never Married, Married (including separated if not legally divorced), Divorced or Widowed, and for Widowed enter the Date of spouse's death. Enter the Spouse's Legal Name (First, Middle Initial, Last, Suffix), Spouse's Date of Birth and Spouse's Social Security Number (optional if not applying).

Enter the Customer's Home Address, Customer's Mailing Address (if different from home address), Phone Number and E-mail Address.

Enter the Name of the Customer's Authorized Representative, Relationship to Customer, Representative Date of Birth (optional) and Name of the Representative Organization (when applicable).

Enter the Authorized Representative's Mailing Address, City, State, ZIP Code, Phone Number and E-mail Address.

Enter the Name of the Customer's Legal Guardian/Conservator and Relationship to Customer.

Enter the Legal Guardian's/Conservator's Mailing Address, City, State, ZIP Code, Phone Number and E-mail Address.

Where is the customer currently residing? Mark Hospital, Nursing Facility, At Home or Other.

Enter Date Admitted, Expected Date of Discharge, the Name of the Hospital, Assisted Living or Nursing Facility, Phone Number, and Address with City, State and ZIP Code.

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

If yes, what kind of alternative format do you need? Please choose one option: Readable PDF sent by secure email, Large print (larger print letters sent by U.S. mail will be provided Arial 24-point font) or Other.

Does the customer need help paying for medical expenses from the last three months? Mark Yes or No. If yes, enter what months.

Is the customer pregnant or had a pregnancy end in the last 5 months? Mark Yes or No.

Is the customer receiving services from the DES Division of Developmental Disabilities? Mark Yes or No. If yes, enter the date services began.

Prior to the age of 18 was the customer diagnosed with any of the following medical conditions? Check all that apply: Autism, Cerebral Palsy, Intellectual/Cognitive Disability, Down syndrome or Seizure Disorder.

If the customer is under the age of 6, has the customer been diagnosed with Developmental Delay? Mark Yes or No.

Is the customer a trustor, trustee, or beneficiary of any type of trust? Mark Yes or No.

Has the customer sold, traded, transferred, or given away any assets within the last five years? Mark Yes or No.

An interview is required to complete the ALTCS application process.

The customer is not required to attend the financial interview if the legal guardian/conservator or authorized representative completes the interview for the customer.

What are the best days and times for you to complete the interview? Mark Monday, Tuesday, Wednesday, Thursday or Friday and enter the Time. Does the person completing the interview need an interpreter? Mark Yes or No. If yes, enter what language.

Enter the Name of Person Completing Form and Phone Number.

If you check Customer, Spouse of the customer, or Parent of the customer (if the customer is a minor), the person completing this form must check the box on the next page and sign this form on the next page.

If one of the boxes is NOT checked, the person completing this form may complete an Authorized Representative form found at https://www.azahcccs.gov/Members/GetCovered/apply.html, attach the completed Authorized Representative form with this request for an application, check the box on the next page and sign this form on the next page.

Check the box I agree to allow you to check information sources and use it for this application, then enter Signature and Date. A request for an application may be returned without the completed authorized representative form, checking the box and signing, but may cause the application process to take more time.

ALTCS customers: please complete the Authorization to Disclose Protected Health Information to AHCCCS form. For use by AHCCCS customers/applicants who want a doctor or other entity to give AHCCCS their protected health information.

A signature on the form is required by one of the following people: Customer; Customer's parent if the customer is under the age of 18; or Customer's Legal Guardian or Legal Representative. Copy of court documents must be provided.

Enter Customer Name, Date of Birth, AHCCCS ID Number or PID, Date of Request, Customer Address and Social Security Number (SSN) (SSN is optional but may help the provider locate records).

Check these boxes to specifically authorize the disclosure of the following types of medical records: under Medical Records, HIV/AIDS and communicable disease related information and/or records, Mental health information and/or records, Genetic testing information and/or records, and Alcohol and drugs screening information and/or records; under School Records, Educational and evaluation records.

Check the box to revoke this authorization upon the following date or event. This authorization will expire on: Insert specific date or Insert specific event.

The customer's signature is required to get medical records. If the customer is under the age of 18, the signature of the customer's parent is needed. If the customer has a legal guardian or legal representative, the signature of the legal guardian or legal representative is needed. Enter Signature, Date, Printed name of person signing form and Relationship to customer.

Enter Printed name of witness (only needed if customer signed with mark) and Signature of witness.

Return this completed form by Fax (toll-free): 888-507-3313 or E-mail: altcsregistration@azahcccs.gov.

A completed Request for Application may also be returned by Online: Health-e-Arizona Plus, Fax (toll-free): 888-507-3313, E-mail: altcsregistration@azahcccs.gov, or Mail: AHCCCS P.O. Box 6050 MD 15023 ALTCS Phoenix AZ 85002-5520. A completed Request for Application may also be taken to a local ALTCS office in Chinle, Phoenix, Flagstaff, Tucson, Kingman or Yuma.