Application Instructions
Who to include on the application:
If you are applying for you or someone in your family, list yourself and everyone in your family who lives with you and is:
- Your spouse;
- Your child/stepchild under age 19;
- Your child/stepchild's child;
- Your child/stepchild's spouse;
- Your child's other parent; and
- A child related to you who you are caring for.
- Include persons who normally live with you but are temporarily not living with you because the person is working or is a child attending school.
If you are applying for someone else (your mother, grandparent, friend, etc.) include the persons who are related (as listed above) to the person for whom you are applying.
If others who are not related as listed above want to apply, complete a separate application.
To speed up the processing of your application, send the information listed below with your application.
Wages: Copies of check stubs or statement from employer showing your gross earnings last month and this month. If someone listed on the application lost a job within the last two months, send proof of the last day worked and the gross amount of the last check received.
Self-Employment: Copies of current Federal tax forms: 1040, SE and applicable schedule C, C-EZ, E, F, K-1, etc. or proof of business income and expenses for the last calendar month.
Other Income: Proof of any other income or money received from any source or for any reason, this and last month. This includes award letters from the Social Security Administration, Veterans Administration, Railroad Retirement, or other retirement or disability pension.
Health Insurance: A copy of insurance ID cards for persons who are applying for medical benefits but who are currently covered by health insurance or attach a piece of paper that lists the company name and policy number.
Citizenship: Copies of both sides of citizenship or immigration documents for persons who want medical coverage and were not born in the United States or its territories. Receiving AHCCCS Medical Benefits will not affect anyone's immigrant status. AHCCCS does not report any information to the Immigration and Naturalization Service (INS).
Daycare: Proof of amount paid for the care of a child or incapacitated adult so an adult in the household can work.
- Health Plan: Choose a health plan from the choices on the back of the next page. Write your choice at the top of Page 1.
Please answer all questions. Use a pen, and print your answers clearly.
Mail the completed application to:
AHCCCS Central Screening Unit
1209 E. Washington St. MD 400
Phoenix, AZ 85034
|