Application Altcs – Fill Out and Use This PDF

Legal Guardian’s/Conservator’s Mailing Address

Customer’s Current Living Arrangement

Hospital, Assisted Living, or Nursing Facility Address

Accommodations for Printed Letters

Does the customer, authorized representative, or legal guardian have a visual impairment that requires an alternative format for printed letters?

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. Other:

Interview Information: 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 applicant.

What are the best days and times for you to complete the interview?

HOW WE WILL USE YOUR INFORMATION

The following information describes how your personal information will be used by Health-e- Arizona Plus, AHCCCS, DES, and their contractors.

•We will use your information, including Social Security number, to computer match with financial institutions, state, local, and federal agencies and our other programs to verify information. Income and verification systems such as the Social Security Administration, State Unemployment Insurance and State Wage may be used. This information may affect eligibility and benefit level.

•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.

The person completing this form is the:

Customer

Spouse of the customer

Parent of the customer (if the customer is a minor)

If one of the boxes above is checked, the person completing this form must:

•check the box below; and

•sign this form below.

•

If one of the boxes above 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 below; and

•sign this form on the next page.

A request for an application may be returned without the completed authorized representative form, checking the box below and signing below, but may cause the application process to take more time.

I agree to allow you to check information sources and use it for this application.

AHCCCS complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

To submit a Request for Application by phone, or for help contact:

Arizona Long Term Care System (ALTCS)

Call (toll-free): 888-621-6880

A completed Request for Application may also be returned by:

•Fax (toll-free): 888-507-3313

•Email: altcsregistration@azahcccs.gov

•Mail: ALTCS

801 East Jefferson Street

MD 3900

Phoenix, AZ 85034

A completed Request for Application may also be taken to a local ALTCS office:

Authorization To Disclose Protected Health

Information To AHCCCS

Attention ALTCS Customer:

Please complete the “Authorization to Disclose Protected Health Information to AHCCCS” form. 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.

Return this completed form using one of the return options below. For any questions, call (602) 417-6600 or toll-free (888) 621-6880. Please note, returning this form quickly will allow us to assist in getting medical documentation for your application.

Return Options:

Fax (toll-free): 888-507-3313

Email: altcsregistration@azahcccs.gov

Mail: AHCCCS

801 E. Jefferson St.

MD 3900

Phoenix, AZ 85034

Authorization To Disclose Protected Health Information

To AHCCCS

For use by AHCCCS customers/applicants who want a doctor or other

entity to give AHCCCS their protected health information.

I give my permission for any health care provider to disclose any of my protected health information to AHCCCS, for the purpose of determining my eligibility for any of the publicly- funded programs administered by AHCCCS. I give AHCCCS permission to share this information with the Arizona Department of Economic Security, Disability Determination Services Administration, if necessary, to determine my disability status.

In addition, by checking these boxes, I specifically authorize the disclosure of the following types of medical records:

HIV/AIDS and communicable disease related information and/or records

Mental health information and/or records

Genetic testing information and/or records

If the information to be disclosed comes from a school, please fill out this box:

I specifically authorize the holder of my information to disclose all of my educational and evaluation records in its possession to AHCCCS.

By signing this Authorization, I understand that:

•AHCCCS is required by state and federal law to keep confidential the information described above and may only use or disclose that information with my approval, for purposes directly related to the administration of the AHCCCS program, or as otherwise permitted or required by law.

•I also understand that if I refuse to sign or revoke this authorization, AHCCCS may not be able to determine my current or future eligibility for the publicly funded medical assistance programs administered by AHCCCS. As a result, my application for assistance may be denied or the assistance may be discontinued.

•I may revoke this authorization, in writing, at any time, by completing an AHCCCS “Revocation of Authorization” form, and sending it to:

Arizona Health Care Cost Containment System Office of Legal Assistance

Attention: Privacy Officer 801 E. Jefferson, MD 6200 Phoenix, AZ 85034 Phone 602-417-4232 Fax 1-602-253-9115

Once AHCCCS receives the revocation, this authorization will be revoked, except to the extent that AHCCCS has already taken action in reliance upon this authorization.

Please choose one of the following:

This authorization will expire on:

Insert specific date:

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.