The BHSF Form 1-MPP Rev. 04/05 is an official Arizona Health Care Cost Containment System (AHCCCS) document. It is used by individuals with physical disabilities who are employed and seeking Medicaid coverage. Applicants must be between 16 and 65 years of age and currently working in Arizona. The form collects personal, employment, financial, and medical information to evaluate Medicaid eligibility.
This prior authorization form is designed for Arizona residents who have a physical disability and are currently employed. The AHCCCS program for working adults with disabilities bridges the gap for people who need medical coverage but do not qualify for standard Medicaid. You should complete this form if you meet all of the following criteria:
Gather the following documents before filling out the application. Having them ready will help you avoid delays.
Personal Information: Enter your full legal name, Social Security number, date of birth, sex, and race. You will also need to provide your address, phone number, and citizenship or immigration status.
Employment and Income: List your employer name, address, and how much you earn. You must also disclose any additional income, including interest, dividends, money from friends or relatives, and unemployment benefits. For each income source, list the amount and how often you receive it.
Health Insurance Status: Report any current health insurance policies. Include the insurance company name and address, group and policy numbers, monthly premiums, and what the policy covers. You must also state whether employer-sponsored health insurance is available to you.
Assets and Resources: List all financial assets. Include checking and savings accounts, retirement accounts, certificates of deposit, annuities, stocks, bonds, and any additional vehicles or real estate beyond your primary home. Provide the value and any amount owed on each asset.
Disability and Healthcare Providers: Describe your disability in detail. List all healthcare providers who are involved in your care. This section is essential for establishing medical eligibility.
After filling out all sections, review your answers carefully. Any errors or missing fields may delay your application. Sign and date the form in the required places. Then submit it using one of these methods:
Always keep a signed copy of the form and all attachments for your own records. You may need them if AHCCCS requests more information.
AHCCCS typically processes Medicaid applications within 30 to 45 days. If your application is approved, you will be enrolled in a managed care plan in your area. You will receive a member ID card and information about how to use your benefits.
If your application is denied, you will receive a written notice explaining the reason. You have the right to appeal any denial. The notice will include instructions on how to file an appeal and the deadlines you must meet.
If you need other types of prior authorization or health coverage forms, the following resources may help:
| 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 |
