Application Altcs PDF Details

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You'll find details about the type of form you want to fill out in the table. It will show you how much time it should take to complete application altcs, exactly what parts you need to fill in and several other specific details.

QuestionAnswer
Form NameApplication Altcs
Form Length7 pages
Fillable?Yes
Fillable fields114
Avg. time to fill out24 min 37 sec
Other namesarizona long term, arizona long term care application, arizona long term care system, altcs

Form Preview Example

Request For Application For Arizona Long Term

Care System (ALTCS)

Customer Address:

To start the application process, you can call us at 888-621-6880 (toll-free). You may also complete this form and return it using one of the methods found on page 4 of this Request for Application.

Customer Information

Customer’s Name (Last, First, Middle)

 

 

 

Customer’s Date of Birth

 

 

 

 

 

 

 

 

Customer’s Social Security Number

 

 

 

Male

Female

 

 

 

 

 

 

 

 

 

 

 

 

Marital Status

Never Married

Married

(including separated if not legally

 

divorced)

 

 

 

 

 

 

 

 

Divorced

Widowed

Date of spouse’s death:

Spouse’s Name (Last, First, Middle)

 

 

 

Spouse’s Date of Birth

 

 

 

 

 

 

Spouse’s Social Security Number (optional if not applying)

 

 

 

 

 

 

 

 

Customer’s Home Address

 

 

Customer’s Mailing Address (if

 

 

 

 

different from home address)

 

 

 

 

 

 

 

 

Phone Number

 

 

E-Mail Address

 

 

 

 

 

 

Authorized Representative/Spouse and Legal Guardian/Conservator Information

Name of the Customer’s Authorized Representative

 

Relationship to Customer

 

 

 

 

 

Name of the Customer’s Legal Guardian/Conservator

 

Relationship to Customer

 

 

 

 

 

 

Authorized Representative’s Mailing Address

 

 

 

 

 

 

 

 

 

 

City

 

 

State

 

Zip Code

 

 

 

 

 

 

Phone Number

 

 

E-Mail Address

 

 

 

 

 

 

 

 

 

 

DE-101_DE-202 Combo form (01/2022)

 

 

 

 

 

 

Page 1 of 7

Legal Guardian’s/Conservator’s Mailing Address

City

Phone Number

State

Zip Code

 

 

E-Mail Address

Customer’s Current Living Arrangement

Where is the customer currently residing?

Date Admitted

Expected Date of Discharge

Hospital

Nursing Facility

 

 

At Home

Other:

 

 

Name of the Hospital, Assisted Living or Nursing Facility

Phone Number

 

 

 

 

Hospital, Assisted Living, or Nursing Facility Address

City

State

Zip Code

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:

Readable PDF sent by secure email

Large print: larger print letters sent by U.S. mail will be provided Arial 24 point font. Other:

Additional Questions

 

 

 

Does the customer need help paying for

Yes

No If yes, what months?

medical expenses from the last three

 

 

 

months?

 

 

 

Is the customer pregnant or had a pregnancy

Yes

No

end in the last 5 months?

 

 

 

Is the customer receiving services from the

Yes

No

DES Division of Developmental Disabilities?

If yes, date services began:

 

 

 

 

Prior to the age of 18 was the customer

Autism

 

Intellectual/Cognitive

diagnosed with any of the following medical

Cerebral

 

Disability

conditions? Check all that apply.

Palsy

 

Seizure Disorder

If the customer is under age of 6, has the

 

 

 

customer been diagnosed with

Yes

No

Developmental Delay?

 

 

 

Is the customer a trustor, trustee, or

Yes

No

beneficiary of any type of trust?

 

 

 

Has the customer sold, traded, transferred, or

 

 

 

given away any assets within the last five

Yes

No

years?

 

 

 

DE-101_DE-202 Combo form (01/2022)

Page 2 of 7

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?

Monday

Time:

Tuesday

Time:

Wednesday

Time:

Thursday

Time:

Friday

Time:

Does the person completing the interview need

If yes, what language?

an interpreter? Yes

No

 

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.

Name of Person Completing Form

Phone Number

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.

DE-101_DE-202 Combo form (01/2022)

Page 3 of 7

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.

Signature

Date

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:

CASA GRANDE

PHOENIX

201 East Cottonwood Lane, Suite 2

801 East Jefferson Street

Casa Grande, Arizona 85122

Phoenix, Arizona 85034

 

 

CHINLE

PRESCOTT

Tseyi Shopping Center, Hwy 191

3262 Bob Drive, Suite 11

Chinle, Arizona, 86503

Prescott Valley, Arizona 86314

 

 

COTTONWOOD

TUCSON

1500 East Cherry Street, Suite I

7202 E Rosewood Street, Suite 125

Cottonwood, Arizona 86326

Tucson, Arizona 85710

 

 

FLAGSTAFF

YUMA

2717 North Fourth Street, Suite 130

1800 E Palo Verde St

Flagstaff, Arizona 86004

Yuma, Arizona 85365

 

 

KINGMAN

 

2400 Airway Avenue

 

Kingman, Arizona 86409

 

DE-101_DE-202 Combo form (01/2022)

Page 4 of 7

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

DE-101_DE-202 Combo form (01/2022)

Page 5 of 7

Authorization To Disclose Protected Health Information

To AHCCCS

Return Information to:

AHCCCS Worker Name:

AHCCCS

 

 

Email:

801 E. Jefferson St. MD 3900

 

 

Phoenix, AZ 85034

 

 

Fax: 888-507-3313

Phone Number:

 

 

 

 

 

 

Customer Name:

 

Date of Birth:

 

 

 

AHCCCS ID Number or PID:

 

Date of Request:

 

 

 

Customer Address:

 

Social Security Number (SSN):

 

 

(SSN is optional but may help

 

 

the provider locate records)

 

 

 

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.

DE-101_DE-202 Combo form (01/2022)

Page 6 of 7

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.

Signature:

Date:

 

 

Printed name of person signing form:

Relationship to Customer:

 

 

Printed name of witness (only needed if

Signature of witness:

customer signed with mark):

 

 

 

DE-101_DE-202 Combo form (01/2022)

Page 7 of 7

How to Edit Application Altcs Online for Free

Our PDF editor was made with the intention of allowing it to be as simple and intuitive as possible. These steps can certainly make filling out the application for altcs in arizona fast and simple.

Step 1: Look for the button "Get Form Here" on this webpage and click it.

Step 2: Now you may enhance the application for altcs in arizona. You can use our multifunctional toolbar to insert, erase, and modify the content material of the form.

Create the following areas to prepare the template:

portion of blanks in applying to altcs online

Include the required information in the EMailAddress, PhoneNumber, StateEMailAddress, and ZipCode section.

step 2 to completing applying to altcs online

In the segment discussing StateEMailAddress, DEDEComboform, and Pageof, it's important to jot down some demanded particulars.

Completing applying to altcs online stage 3

The City, PhoneNumber, State, ZipCode, EMailAddress, HospitalAtHome, NursingFacilityOther, DateAdmittedExpectedDateofDischarge, PhoneNumber, City, State, ZipCode, and YesIfyeswhoneedstheaccommodation box is the place to insert the rights and responsibilities of both sides.

stage 4 to completing applying to altcs online

Finalize the document by looking at the following fields: Yes, NoIfyeswhatmonths, Yes, Yes, Ifyesdateservicesbegan, IntellectualCognitive, Disability, SeizureDisorder, AutismCerebral, Palsy, Yes, Yes, and Yes.

applying to altcs online Yes, NoIfyeswhatmonths, Yes, Yes, Ifyesdateservicesbegan, IntellectualCognitive, Disability, SeizureDisorder, AutismCerebral, Palsy, Yes, Yes, and Yes fields to fill

Step 3: As soon as you are done, click the "Done" button to upload the PDF document.

Step 4: Produce copies of your form. This should protect you from possible issues. We do not read or display the information you have, as a consequence you can be confident it is protected.

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