Question	Answer
Form Name	Arkids Application
Form Length	4 pages
Fillable?	Yes
Fillable fields	170
Avg. time to fill out	35 min 4 sec
Other names	forms arkids online, forms arkids, arkids in application, arkids health insurance application printable

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)

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) _ _ _ - _ _ - _ _ _ _

30. DISABILITY STATUS Do you have a disability?		Yes	No	Or are you blind?	Yes No
Do you live in a medical facility or nursing home?		Yes	No
What type of facility is this?	Nursing Home	Human Development Center			Arkansas State Hospital
Arkansas Health Center	Intermediate Care Facility for the Intellectually Disabled


Yes	No	If yes, please provide your good cause reason:
FOSTER CARE STATUS
18. Was PERSON 2 in foster care in Arkansas at age 18 or older?					Yes	No
If yes, was PERSON 2 enrolled in Medicaid when they left the Foster Care program?							Yes	No
Is PERSON 2 currently enrolled in Medicaid?			Yes	No

Employed	Not Employed	Self Employed
If PERSON 2 currently employed tell us about	Skip to Question 28.	Skip to Question 29.
their income. Start with question 20.

22. Wages/tips (before taxes)		$
Hourly	Weekly	Every 2 Weeks		Twice a Month	Monthly		Yearly

1. Is anyone enrolled in health coverage now from the following?				Yes	No
	If yes, check the type of coverage and write the person(s)’ name(s) next to the coverage they have.
	Name of Health Insurance				Other Insurance

Policy Number				Name of Health Insurance
Is this cobra coverage?		Yes	No	Policy Number
Is this a retiree plan?		Yes	No	Is this a limited benefit plan (like a schoolaccident policy)?		Yes	No
Other Health Coverage
	Medicaid				ARKids First/CHIP

	Medicare				Peace Corp

	VA Health Care Programs

	TRICARE (Don’t check if you have Direct Care or Line of Duty)

county jail, city jail or a JuvenileDetention Facility?	Yes	No
If Yes, who?			_
What is the incarcerated person’s expectedrelease date?				_ (mm/dd/yyyy)

Yes, review my eligibility automatically for the next:
5 years (The maximum number of years allowed) Or for a shorter number of years:	4 years	3 years	2 years	1 year
Don’t use information from tax returns to review my eligibility.

Mail your signed application to:
DHS Pine Bluff Scanning Center	Or email the application to: 351Jefferson@arkansas.gov
P.O. Box 8848	Or fax the application to:1-870-534-3421.
Pine Bluff, AR 71611-8848	Or submit the application to your local DHS Office.

Would you like to register to vote or change your voter registration	Yes
address?

Arkids Application – Fill Out and Use This PDF

Arkids Application PDF Details