Care 1St Arizona Prior Authorization Form – Fill Out and Use This PDF

The Care 1st Arizona Prior Authorization form, designated as BHSF Form 1-MPP Rev. 04/05, is an essential document for individuals with disabilities who are working, aged between 16 and 65, and seeking healthcare coverage through Medicaid. It collects detailed information about the applicant’s personal details, employment, income, other financial resources, healthcare needs, and more, to evaluate eligibility for Medicaid services. If you are looking to apply for this Medicaid option, ensure all sections of the form are completed accurately. To begin filling out your form, click the button below.

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Care 1St Arizona Prior Authorization Form PDF Details

In today's healthcare landscape, navigating the paperwork required to access services can often feel overwhelming for patients and healthcare providers alike. Among these necessary documents, the Care 1st Arizona Prior Authorization form stands out as a critical piece of the puzzle for those seeking healthcare coverage, particularly for persons with disabilities who are employed and fall within the age range of 16 to 65. This form, also known as the BHSF Form 1-MPP, has undergone revisions, the latest being in April 2005, underscoring its evolving nature to better meet applicant needs. Its primary function is to facilitate the evaluation process for Medicaid eligibility, ensuring that all necessary personal information, employment details, income sources, assets, and health insurance status are thoroughly documented. Additionally, it delves into an individual’s disability details and requires disclosure of any health care providers involved in the applicant's care. It's noteworthy that the form provides space for applicants to indicate their preferred language for communication, acknowledging the linguistic diversity and promoting inclusiveness. Importantly, the form places a strong emphasis on honesty and accuracy of the provided information, with stern warnings about the consequences of fraud. It also outlines the applicant's rights and responsibilities, including the stipulation to report any changes in circumstances that could affect their eligibility. This careful balance between gathering exhaustive personal information and ensuring applicant understanding and compliance reflects the form's central role in the broader goal of making healthcare accessible to those with disabilities who are striving to maintain employment.

Question	Answer
Form Name	Care 1St Arizona Prior Authorization Form
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	1st authorization form, care 1st az prior auth form, az health authorization request, 1st prior authorization

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BHSF Form 1-MPP

Rev. 04/05

Prior Issue Obsolete

For Agency Use Only

Request date

(Application date)

Date mailed

Agency Rep

To protect your application date, we must receive this application by

(for agency use only)

What language do you speak best? English Spanish Vietnamese Other (specify) What language do you write best? English Spanish Vietnamese Other (specify)

If you do not speak English we can get interpreter services to help at no cost to you. If you need help to fill out this form, call your local Medicaid office or call us toll free at 1+888+544-7996. If you are deaf or have hearing problems, call the TTY line toll free at 1+800+220-5404.

This application is to get healthcare coverage for persons with disabilities who work and who are at

least age 16 but not yet age 65. If you want Medicaid for anyone else, check ( ) this . We will send you information about applying for other Medicaid coverage. Please fill out every item on this form. If an answer to a question is none or 0, write “none”. If you need more space for any item, use a separate sheet.

1.Tell us who YOU are, where YOU live, and where YOU get your mail:

Name

Parish

Home address

City

State

Zip code

Mailing address

City

State

Zip code

Home phone ( )

Daytime phone (

)

2.Tell us about yourself and your spouse. You do not have to give your spouse’s Social Security number if he or she is not applying. If given, the number will only be used to verify assets.

You do not have to give race information. If you choose to do so, use the following codes: 1=White; 2=Black; 3=American Indian/Alaskan; 4=Asian; 5=Hispanic/Latino; 6=Hawaiian/Pacific Islander; 7=Hispanic/Latino & Other; 8=Multi-Race, Not Hispanic; 9=Unknown

Name - first, middle initial, last	Social Security	Date of birth			Sex	Race	US citizen/	Louisiana	Relation to you
	number	Month	Day	Year	M/F		Legal alien	resident

Yes	No	Yes	No	self



Yes	No	Yes	No	spouse
				spouse

3.Tell us about EACH job or business that you have. Show the amount of total or gross income before any deductions, not your take-home pay. (Send copies of pay check stubs or other proof of your earnings for last month. If you are self-employed, send copies of your most recent federal tax form with all schedule attachments. Send other proof if you do not have tax forms.)

Employer name, address & phone OR	Amount	How often do	# of hours
Self-employment information	paid	you get paid?	worked per week

4.Do you get any money like the kinds listed below? Yes No

Social Security	Unemployment	Money from friends
Retirement/Pensions/Annuities	Workman’s Compensation	or relatives
Veteran’s Benefits	Interest/Dividends/Royalties	Any other not listed

(Show all money that you get and send proof of the income. You do not have to send proof of Social Security or Unemployment income.)

Income type	Source name,		How much	How often
Income type	address, & phone		do you get?	do you get it?
	address, & phone		do you get?	do you get it?
		$

Have you ever applied for money from any of these sources? Yes No If Yes, when and from which ones?

5.Do you have Medicare or other health insurance? Yes No If Yes, answer the following. (Send proof of coverage and premium payment.)

Insurance company name,	Group/policy number	Monthly		Policy covers:
address, & phone	Group/policy number	cost	hospital		doctor	ambulance
address, & phone		cost	hospital		doctor	ambulance

Can you get health insurance from your employer? Yes No

6.Do you, or you jointly with your spouse, have any assets or resources like those listed below? Yes No If Yes, give us the following information. (Send proof of ownership and value.)

Asset/Resource	Company name, address, & phone;	Value	Amount owed
	Company name, address, & phone;
	Account number and/or description
	Account number and/or description
Checking/Savings accounts (type)		$

Certificates of Deposit		$
Retirement accounts		$
Annuities/Trusts		$
Stocks/Bonds		$
Vehicles (if more than one)		$	$
Property, other than your home		$	$
Other (please be specific)		$	$

7.Did you ever apply for or get Social Security Disability or Supplemental Security Income (SSI)

benefits? Yes No If Yes, when?			Was a decision made? Yes No
If Yes, what was the decision?

8.What is your disability?

Tell us about the doctors or other medical providers who care for you:

Provider’s name(s)

Address & phone of this medical provider

9.Where did you find out about the Medicaid Purchase Plan?

Rights and Responsibilities

I declare that I am a U.S. citizen or in this country legally.

The information I gave on this form is true and correct to the best of my knowledge. I realize if I knowingly give information that is not true OR if I knowingly hold back information, I may get health benefits for which I am not eligible. If that happens, I can be lawfully punished for fraud. I may also have to pay Medicaid back for any medical bills which are paid incorrectly.

I understand that the information I give about my situation will be checked. I agree to help do that, and to let Medicaid get information it needs from government agencies, employers, medical providers, and other sources. If I refuse to help with this process or in later reviews caused by reported changes, or as part of a Recipient Eligibility review, it will mean that I can’t get Medicaid until I do help.

I know that Social Security numbers will only be used to get information from other government agencies to prove my eligibility.

I agree to tell Medicaid within 10 days if 1) I move out of state; 2) there are changes in where I live or get my mail; 3) there are any changes in other health insurance coverage; 4) there is any change in my work status.

By accepting Medicaid, I agree that any medical payments received from other sources will be sent to the Department of Health and Hospitals for any services that were covered by Medicaid.

I can ask for a Fair Hearing if I think the decision made on my case is unfair, incorrect or being made too late.

Medicaid can’t treat me differently because of my race, color, sex, age, disability, religion, nationality or political belief. If I think they have, I can call the U.S. DHHS Regional Office for Civil Rights in Dallas, TX at 1+800+368-1019 or write to Louisiana’s Department of Health & Hospitals, Human Resources at P. O. Box 1349 Baton Rouge, LA 70821-1349.

Signature of Applicant or Authorized Representative		Date

Signature of Agency Representative, if applicable		Date

How to Edit Care 1St Arizona Prior Authorization Form Online for Free

The PDF editor that you will begin using was developed by our number one software engineers. You can easily create the plan treatment authorization template file promptly and without problems with our app. Just keep up with the following guideline to get going.

Step 1: You can choose the orange "Get Form Now" button at the top of this page.

Step 2: After you have accessed the editing page plan treatment authorization template, you should be able to notice every one of the functions available for the file in the upper menu.

For you to fill in the form, enter the details the application will ask you to for each of the next parts:

Inside the box Tell us who YOU are where YOU, Daytime phone, Tell us about yourself and your, Name first middle initial last, Social Security number, Date of birth Day, Year, Month, Sex MF, Race, US citizen Legal alien, Louisiana resident, Relation to you, Yes No Yes No cid cid cid cid Yes, and self enter the information that the platform requires you to do.

1st authorization form Tell us who YOU are where YOU, Daytime phone, Tell us about yourself and your, Name first middle initial last, Social Security number, Date of birth Day, Year, Month, Sex MF, Race, US citizen Legal alien, Louisiana resident, Relation to you, Yes No Yes No cid cid cid cid Yes, and self fields to fill

Describe the significant information in the Do you get any money like the, cid InterestDividendsRoyalties cid, cid Money from friends or relatives, cid Unemployment, Income type, Source name address phone, How much do you get, How often do you get it, Have you ever applied for money, Do you have Medicare or other, Insurance company name address, Grouppolicy number, Monthly cost, and Policy covers segment.

step 3 to filling out 1st authorization form

Inside of field Insurance company name address, Grouppolicy number, Monthly cost, Policy covers, hospital, doctor ambulance, cid cid cid, cid cid cid, and Can you get health insurance from, state the rights and responsibilities.

1st authorization form Insurance company name address, Grouppolicy number, Monthly cost, Policy covers, hospital, doctor ambulance, cid cid cid, cid cid cid, and Can you get health insurance from fields to complete

Finalize by taking a look at the following areas and completing them accordingly: AssetResource, Company name address phone, Value, Amount owed, CheckingSavings accounts type, Certificates of Deposit, Retirement accounts, AnnuitiesTrusts, StocksBonds, Vehicles if more than one, Property other than your home, Other please be specific, Did you ever apply for or get, and What is your disability.

step 5 to finishing 1st authorization form

Step 3: After you hit the Done button, your ready document can be easily exported to any kind of your devices or to email indicated by you.

Step 4: Produce copies of the document. This can protect you from possible future misunderstandings. We don't see or publish your data, for that reason be assured it will be secure.

Care 1St Arizona Prior Authorization Form – Fill Out and Use This PDF

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