Please rate Apply For Ahcccs 08-2026
Keep pages A, B, C, D, E, F, and G for your records.
Who completes it: you or anyone you choose who knows or can get the information needed to complete the application for you and your family members.
Spouses: you and your spouse can use the same application form to apply.
Guardian: if you have a conservator or guardian, your conservator or guardian must complete this form for you.
Medicare: if you are receiving or eligible for Medicare Part A, use this application to apply for help with your Medicare premium(s), copayments and deductibles.
Verification: attach all requested verification when you send your application.
| Question | Answer |
|---|---|
| Form Name | DE-103 |
| Form Length | 18 pages |
| Fillable? | Yes |
| Fillable fields | 291 |
| Avg. time to fill out | 49 min |
| Edition | Rev 08/2026 |
| Where to send | Mail, fax or take pages 1 through 6 to the MA-SP Office |
| Other names | DE-103, DE 103, DE103, AHCCCS application, AHCCCS Medical Assistance application, Application For AHCCCS Medical Assistance and Medicare Savings Programs |
| Official source | DE-103 (Rev 08/2026), Arizona Health Care Cost Containment System |
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