Arkids Application PDF Details

The ARKids Application is the official document for applying to health coverage programs in Arkansas, including full Medicaid, ARKids First, and the Arkansas Works Program. The form accepts applications from families with children under age 19 who need affordable or no-cost healthcare coverage.

To qualify for ARKids First, children must be Arkansas residents, U.S. citizens or eligible immigrants, under 19 years old, and from families that meet the program income guidelines. ARKids A covers children from lower-income families and provides full Medicaid benefits. ARKids B (the Children's Health Insurance Program, or CHIP) covers children from families with slightly higher incomes who do not have access to affordable employer-sponsored coverage.

Applicants must supply personal and family details, including Social Security numbers, income information, employment status, and current health insurance coverage. The application also includes a Voter Registration section and a consent form for anyone assisting with the process. Language assistance is available through the Arkansas DHS helpline for non-English speakers.

Families of all compositions may apply, including those with immigrant members. Immigration status alone does not prevent a family from applying, though certain programs may have citizenship requirements. Those with unpaid medical bills or in foster care situations will find relevant sections in the form for their circumstances.

FormsPal also provides access to related government health coverage forms, including the Georgia Medicaid Application and the Health Insurance Application form, for families in other states seeking similar coverage.

QuestionAnswer
Form NameArkids Application
Form Length14 pages
Fillable?No
Fillable fields0
Avg. time to fill out3 min 30 sec
Other namesarkids health insurance application printable, arkids medicaid application, ar kids application, arkids application

Form Preview Example

HOUSEHOLD HEALTH

COVERAGE APPLICATION

Frequently Asked Questions

What is the fastest way to apply for coverage?

The fastest way to apply for coverage is to apply online at: https://access.arkansas.gov/

What services can I apply for with this application?

You can apply for Medicaid, ARKids First or the Arkansas Works Program.

If you are not eligible for any of the above coverage, your information will be transferred to the Federally Facilitated Health Insurance Marketplace to determine your eligibility for tax credits to help pay for a Qualified Health Plan.

Who can use this application?

Use this application to apply for you or anyone in your family.

Apply even if you or your child already has health coverage. You could be eligible for lower cost or free coverage.

Families that include immigrants can apply. You can apply for your children even if you are not eligible for coverage. Applying won’t affect your immigration status or chances of becoming a permanent resident or citizen.

If someone is helping you fill out this application, you may need to complete a DCO-153, Consent for an Authorized Representative.

What will I need to apply?

Your Social Security number (or document number if you are a legal immigrant)

Employer and income information (examples: from recent paystubs, W-2 forms, or wage and tax statements)

Information about any job related health insurance available to your family

Policy numbers for any current health insurance

Why do you need my Social Security number, employer, and income information?

We ask about income and other information to let you know what coverage you qualify for and if you can get help paying for it. We’ll keep all the information you provide private and secure as required by law. To view the Privacy Act Statement go to: https://access.arkansas.gov/.

What if I need help with my application?

You can contact the Help Center at 1-855-372-1084 or contact your local DHS county office. En Español: Llame a nuestro centro de ayuda gratis al 1-855-372-1084.

Why is there a Voter Registration application included?

A Voter Registration packet is included with this application to provide an opportunity for

you to register to vote or change your voter registration address. By applying to register or declining to register to vote will not affect the amount of assistance that you will be provided by this agency.

DCO-152 (09/18)

Page 1 of 8

Step 1: Tell Us About Yourself

(We need one adult in the family to be the contact person for your application.)

1. First Name, Middle Name, Last Name & Suffix

2. Home Address

 

 

 

 

 

 

3. Apartment or Suite Number

 

 

 

 

 

 

 

 

 

 

 

 

4. City

 

 

5. State

6. ZIP Code

 

7. County

 

 

 

 

 

 

 

 

 

 

 

8. Mailing Address (If different from home address)

 

 

 

 

 

9. Apartment or Suite Number

 

 

 

 

 

 

 

 

 

 

 

 

 

10.

City

 

 

11. State

12. ZIP Code

 

13. County

 

 

 

 

 

 

 

 

 

 

 

 

14. Phone Number

 

 

 

 

15. Other Phone Number

 

 

 

 

 

 

 

 

 

 

 

16.

Do you live in the State of Arkansas?

Yes

No

17. If you are currently out-of-state, do you intend to return to Arkansas?

Yes

No

 

 

 

Email Address: Providing a valid email address will allow us to process your application and provide you with notice updates more efficiently.

 

Providing an email address will allow you to receive information regarding your health coverage in real time through your email account.

 

18.

Email Address:

 

 

 

 

19. I do not want to provide an email address at this time.

 

 

 

 

 

 

 

 

 

20.

Preferred spoken or written language (if not English)

 

 

 

 

 

Step 2: Tell Us About Your Family

Who do you need to include on this application?

List all the people who live in your home, including yourself. If you file taxes, we need to know about everyone on your tax return. This includes your tax dependents that do not live in your home. (You don’t need to file taxes to be eligible for health coverage.)

The amount of assistance or type of program you qualify for depends on the number of people in your family and their incomes. This information helps us make sure that everyone receives the best coverage they can.

Complete Step 2 for each person in your family. Start with yourself, then add other adults and children. If you have more than two people in your family, you will need to fill out a form DCO-152C, Additional Household Member, for each additional member of your household and attach the form(s) to this application. You don’t need to provide immigration status or a Social Security Number (SSN) for family members who do not need health coverage. We will keep all the information you provide private and secure as required by law. We will only use your personal information to check if you are eligible for health coverage.

Please proceed to Step 2, Person 1 on the following page.

NEED HELP WITH YOUR APPLICATION? Call us at 1-855-372-1084. Para obtener una copia de este formulario en Español, llame 1-855-372- 1084. If you need help in a language other than English, call 1-855-372-1084 and tell the customer service representative the language you need. We will get you help at no cost to you.

DCO-152 (09/18)

Page 2 of 8

Step 2: Person 1

Complete Step 2 for yourself, your spouse/partner and children who live with you and/or anyone on your same federal income tax return if you file one. See page 2 for more information about who to include. If you don’t file a tax return, remember to still add family members who live with you.

1.

First Name, Middle Name, Last Name & Suffix

2. Relationship to you?

3. Sex

 

 

 

 

 

SELF

 

Male

 

Female

 

 

 

 

 

 

4. Date of Birth (mm/dd/yyyy)

5. If you are under 18, are you emancipated?

 

Yes

 

No

 

 

If Yes, how were you emancipated?

Court Order

 

Common Law

 

 

 

 

 

 

 

6.

Social Security Number (SSN) _ _ _ - _ _ - _ _ _ _

 

 

 

 

We need this if you want health coverage and have an SSN. Providing your SSN can be helpful if you don’t want health coverage too since it can speed up the application process. We use SSNs to check income and other information to see who is eligible for help with health coverage costs. If someone wants help getting an SSN, call 1-800-772-1213 or visit ssa.gov. TTY users should call 1-800-325-0778.

7. Do you currently have health coverage and want to continue with the same coverage?

 

 

Yes

No

If No, would you like to apply for coverage?

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CITIZENSHIP STATUS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8. Are you a U.S. citizen or U.S. national?

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

Are you a citizen of the Marshall Islands, Federated States of Micronesia or Palau?

Yes

No

9. If you are not a U.S. citizen or U.S national, do you have eligible immigration status?

 

 

 

 

 

 

 

Yes Enter your document type and ID number below.

 

 

No

 

 

 

 

 

 

a.

Immigration document type:

 

 

 

 

 

 

 

 

Alien #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

b.

Document ID number:

 

 

 

 

 

 

 

 

 

_ Expiration date of document

 

 

 

c. Have you lived in the U.S. since 1996?

 

Yes

 

No

 

Date of entry into U.S.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

d. Are you or your spouse or parent a veteran

or an active duty member of the U.S. military?

 

 

 

10.

If Hispanic/Latino, what is your ethnicity and race? (OPTIONAL – Check all that apply.)

 

 

 

 

 

 

 

 

 

Mexican

 

Mexican-American

Chicano/a

Puerto Rican

Cuban

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11.

Race (OPTIONAL – Mark (X) all that apply.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Race

X

Race

X

Race

 

 

 

 

 

X

Race

 

X

Race

 

X

Race

 

X

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

White

 

Filipino

 

Black/African American

 

 

 

Alaskan Native

 

Hawaiian/Pacific Islander

 

Samoan

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Korean

 

Japanese

 

American Indian

 

 

 

Asian Indian

 

 

Guamanian or Chamorro

 

Chinese

 

 

 

PREGNANCY STATUS

 

 

If yes, what is your expected due date?

 

 

 

 

 

 

12. Are you pregnant?

Yes

No

 

 

(mm/dd/yyyy)

 

How many babies are you expecting during this pregnancy?

 

 

If no, have you delivered a child in the last 90

 

 

 

days?

Yes

No If yes, what was the date of delivery?

 

If yes, how many babies did you deliver? _

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FOSTER CARE STATUS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13. Were you in foster care in Arkansas at age 18 or older?

Yes

No

 

 

 

 

 

 

If yes, were you enrolled in Medicaid when you left the Foster Care program?

Yes

No

 

 

 

 

Are you currently receiving Medicaid?

 

 

Yes

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14. Are you the main caregiver living with and taking care of at least one child under the age of 19?

Yes

No

 

TAX FILING STATUS

15. Do you plan to file a federal income tax return NEXT YEAR? (You can still apply for health coverage even if you don’t file a federal income tax return.)

YES If yes, please answer questions a through c.

 

 

 

NO If no, skip to question c.

a.

Will you file jointly with a spouse?

Yes

No

 

 

 

 

 

 

If yes, name ofspouse:

 

 

 

 

 

 

 

 

b.

Will you claim any dependents on your tax return?

 

Yes

No

 

 

 

 

If yes, list name(s) of dependents:

 

 

 

 

 

 

 

 

c.

Will you be claimed as a dependent on someone’s tax return?

 

Yes

No

 

If yes, please list the name of the tax filer:

 

 

 

 

_

 

How are you related to the tax filer?

 

 

 

 

 

 

 

 

 

DCO-152 (09/18)

Page 3 of 8

How to Edit Arkids Application Online for Free

What You Need to Complete the ARKids Application

Before starting the Arkansas health coverage application, gather these documents:

  • Social Security numbers for all household members applying for coverage
  • Proof of Arkansas residency (utility bill, lease agreement, or government-issued document)
  • Income documentation for all adults in the household (pay stubs, tax returns, or employer statements)
  • Birth certificates or other proof of age for each child applying
  • Information about any current health insurance coverage held by the family

Our PDF editor makes it simple to create forms. You won't need to do much to manage how to complete the arkids application forms. Just simply stick to all of these actions.

Step 1: The initial step is to click the orange "Get Form Now" button.

Step 2: At this point, you are on the file editing page. You may add content, edit present data, highlight specific words or phrases, put crosses or checks, add images, sign the file, erase unrequired fields, etc.

These parts are within the PDF file you'll be filling in.

entering details in arkids application online step 1

Type in the demanded data in the field Why do you need my Social Security, What if I need help with my, Why is there a Voter Registration, DCO, and Page of.

Filling in arkids application online stage 2

Provide the key particulars in the We need one adult in the family to, Home Address, City, State, ZIP Code, County, Apartment or Suite Number, Mailing Address If different from, Apartment or Suite Number, City, Phone Number, State, ZIP Code, County, and Other Phone Number box.

Finishing arkids application online stage 3

The space Complete Step for yourself your, First Name Middle Name Last Name, Relationship to you, Sex, SELF, Male, Female, Date of Birth mmddyyyy, If you are under are you, If Yes how were you emancipated, Yes Court Order, No Common Law, Social Security Number SSN, Do you currently have health, and Yes is where to place each side's rights and obligations.

Filling out arkids application online part 4

Finish by reviewing the next areas and filling out the required data: Race OPTIONAL Mark X all that, Race, X Race, X Race, X Race, X Race, X Race, White, Korean, Filipino, BlackAfrican American, Alaskan Native, HawaiianPacific Islander, Japanese, and American Indian.

Completing arkids application online stage 5

Step 3: When you choose the Done button, your prepared file may be exported to all of your gadgets or to electronic mail provided by you.

Step 4: It could be simpler to prepare duplicates of your document. There is no doubt that we will not disclose or view your data.

ARKids First Coverage Benefits

Children enrolled in ARKids First receive comprehensive healthcare coverage through either ARKids A (full Medicaid) or ARKids B (CHIP). Both programs cover a wide range of medical services for eligible children in Arkansas:

  • Routine doctor visits and preventive care checkups
  • Hospital stays and emergency care
  • Prescription medications
  • Dental and vision care for children
  • Mental health services and substance use treatment
  • Medical equipment and rehabilitation services

Families who need help with other health coverage forms can also access the Medicaid application form, the North Carolina Medicaid application, or the health insurance renewal form on FormsPal.

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