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Arizona Department of Economic Security/F amily Assistance Administration (DES/FAA) Arizona Health Care Cost Containment System (AHCCCS) Application for Benefits Tear off and keep pages A through H for your records. What is this application for? Use this application to see if you and members of your household qualify for:  Free or low-cost insurance from AHCCCS  Help with your Medicare costs  Nutrition Assistance  Cash Assistance/Temporary Assist ance for Needy Families (TANF)  Tuberculosis Control  A new tax credit that can help pa y your health insurance premiums See page B for a description of each program. Who can use this application? An application may be completed by you or anyone you choose who knows or can get the information needed to complete the application for you and your household member s. You can use this application to appl y for anyone in your household, even if th ey already have benefits, including health insurance. Your household includes:  Your spouse, if married  Your children under age 22 who live with you  Your partner who lives with you (but only if you have a child together who needs health insurance or Cash Assistance)  People you claim on your income tax return even if they do not live with you  Relatives in your care who are under the age of 19 and live with you  People who you live with that pur chase and prepare food with you If you want to select a represen tative to complete your applic ation, complete the Authorized Representative form on page 1 of t he application. Where else can I apply? You can apply faster online at www.healthearizonaplus.gov. You can also apply in person at any local Department of Economic Security (DES)/Famil y Assistance Administration (FAA) office. You can find a list of local FAA offices at www.azdes.gov/faa or call our 24 hour Interactive Voice Response system at 1-855-HEA- PLUS (432-7587). What information do I need to complete this application? For everyone in your household, you may need:  Birth dates  Social Security numbers  Employer and income information for everyone in your household  Resources (e.g., bank account, cash, property)  Expenses  Information for any current health insurance  Information about any job-related health insu rance available to members of your household  Other information needed to complete your application Note: You can file an application with only yo ur name, address, and the si gnature of a responsible household member or your authorized representative. This will hold your date of application but eligibility cannot be determined until you complete a full application and an interview, if needed. Why do we ask for so much information? We ask about income and other information to make sure you and members of your household get the correct benefits for your household. We will keep all information you provide private, as required by law. What happens next? Send your completed, signed application to the address on Page 17 or take it to your local DES o ffice. If you do not have all of the information available, you can still submit your applicatio n and we will help you get the rest of the information. What if I need help? If you need help filling out this application, please tell us. If you need a language interpreter or accommodations for a disability, please check the kind of help you need on page 1 of the application. Online: www.healthearizonaplus.gov Phone: 1-855-HEA-PLUS (432-7587) In person: Visit www.azdes.gov/faa to find the office closest to you. Page A FA-001 (11/2016) Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587). FA-001 (11/2016)   Page B   Program Information: You can use this application to apply for one or more programs. Each program has a symbol. On the application, look for the symbol for the program(s) you want to apply for and answe r those questions. These ar e the symbols you will see on this application: = Health Insurance Costs (AHCCCS Medical Assist an ce, Medicare Savings Program, Tax Cre d its) = Nutrition Assistance $ = Cash Assistance = Tuberculosis Control What is AHCCCS Medical Assistance? AHCCCS stands for Arizona Health Care Cost Containm ent System, and it is the State of Arizona’s Medicaid program. AHCCCS can provide medi cal benefits and help with Medicare costs to Arizona residents who meet certain income and other eligibility standards. AHCCCS Medical Assistance covers the following medical services:  Prescription Medication *  Medical Supplies  Chemotherapy  Doctor's Office Visits**  Medicall y Necessar y Transportation  Emer g enc y Medical Ca  Laboratory and X-ray Services  Hospital Services  Dial y sis  Medically Necessar y Specialist Care  Behavioral Health Care  Immunizations ( shots )  Rehabilitation Services  90 days of nursing care services * AHCCCS prescription coverage is limited for people who have Medicare. ** Wellness visits for people age 21 and over are not covered. What is Medicare Savings Program? Medicare Savings Program may pay:  Medicare Part A premium  Medicare Part B premium  Medicare deductibles and copayments  Automatic Extra Help for Medica re Part D prescription expenses What are Nutrition Assistance benefits? Nutrition Assistance benefits help low-income families or individuals buy food for a healthier diet. If you have little or no money, you may be eligible for Emergency Nutr ition Assistance benefits. Be sure to answer the Emergency Nutrition Assistance benefits questions on page 2 of this application. What is Cash Assistance? $ Cash Assistance gives tem porary cash benefits to low income families. Pare nts or relatives of dependent children who are in their care may be eligible. So me families may qualify for a one-time lump sum cash assistance payment. We will determine if you qualify for this payment option. What is Tuberculosis Control? Tuberculosis Control gives cash support to individuals who are determined unable to work by the Department of Health Services as a result of communicable Tuberculosis. What if I am not eligible for AHCCCS Medical Assistance? If you are not eligible for AHCCCS Medical Assistance, y ou may be eligible for federal tax credits to help with your health insurance premiums . If you are not eligible for any progra ms through AHCCCS, we will send your information to the federal Health Insurance Mark etplace to see about health insurance tax credits. Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587). FA-001 (11/2016)   Page C   How does AHCCCS Medical Assistance work? If you are approved for AHCCCS Medical Assistance, you will receive your health care from an AHCCCS health plan unless:  You are American Indian and you choose American Indian Health Program as your health plan.  You are just asking for help with your Medicare co sts. If you are approved for one of the Medicare Savings Programs (QMB), AHCCCS may pay your Medicare premiums and Medicare coinsurance and deductibles.  AHCCCS can only pay for your emergency services because of your stat us with United States Citizenship and Immigration Services (USCIS). If you are approved for emergency services only, you may receive medical services from any provider (doctor, hospital, etc.) that has an agreement to bill AHCCCS for covered emergency services. How much does AHCCCS Medical Assistance cost? Premiums:  Most people do not have to pay a monthly premium for AHCCCS Medical Assistance.  Some people with income too high to qualify fo r AHCCCS Medical Assistance with no monthly premium may be able to get it by paying a monthl y premium. If you have to pay a premium, the premium amounts are:  $10 to $35 for customers on the Freedom to Work program.  $10 to $70 for customers on the KidsCare program. Co-payments: A co-payment is the amount you pay a health care provider when you receiv e a medical service. Your co-payment amount will vary depending on which AHCCCS program you are enrolled in and the services you need. For some AHCCCS programs , the provider can deny services if the co- payments are not made. Co- payments for services are:  $2.30 to $10.00 for prescriptions  $0 to $30.00 for non-emergency use of an emergency room  $3.40 to $5.00 for outpatient visits for evaluati on and management services including doctor’s office visits  $2.30 to $3.00 for physical, occupational or speech therapy Remember to report any changes in income because this may change your co-payment amount. The following people are never asked to pay co-payments:  Children under age 19  People determined to be Seriously Mentally Ill (SMI) by the Arizona Department of Health Services  Individuals through age 20 eligible to receive services from the Ch ildren’s Rehabilitative Services (CRS) program  People who are temporarily residing in nursing homes or residential facilities such as an Assisted Living Home and only when the acut e care member’s medical condition would otherwise require hospitalization. The exempt ion from co-payments is limited to 90 days in a contract year  People who receive hospice care Co-payments are never charged for the following services for anyone:  Hospitalizations  Services paid on a fee-for- service basis  Emergency services  Pregnancy related health care including tobacco cessation for pregnant women  Family planning services Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587). FA-001 (11/2016)   Page D   Do I need a Social Security number? $ Federal law requires you give a Social Security number (SSN) for anyone who wants to get AHCCCS Medical Assistance, help with Medicare costs, Nutrition Assistance, Cash Assistance, and/or Tuberculosis Control (42 U.S.C. § 1320b-7; 42 U.S.C. § 405(c)(2)(C), 7 U. S.C. §§ 2011-2036, and Social Security Act (SSA) of 1935 (Section 1137) as amended by P.L. 98-369).  If you or anyone you are applying fo r does not have a Social Security number, we will refer you to the Social Security office to apply for one. Immigrants who are not legally able to get a Social Security number are not required to give one or apply for one. Any person you are applying for who is legally able to get a Social Security number but does not have one or does not apply for one will not be eligible for benefits.  If you are not applying for benefits for yourself, you do not have to give us your Social Security number. However, it may reduce the total amount of Nutrition Assistance and/or Cash Assistance benefits for the person you are applying for because we will not in cl ude you in the benefit amount.  We will not use your SSN as your D ES or AHCCCS identification number.  We will not give any Social Security numbers to the United States Citi zenship and Immigration Services (USCIS). We use your information, including Social Security number, to:  Verify identity  Verify citizenship and immigration status  Verify income and resources  Prevent duplicate benefits  Establish and enforce child support  Computer match with state, local and federal agen cies and our other programs to verify information  Collect money we overpaid you in the form of benefits  Share with other government agencies and their contra ctors to assess Nutrition Assistance and/or Cash Assistance program management and compliance  We may give your information to law enforcement o fficials for the purpose of arresting persons fleeing to avoid the law If we are not able to find proof of t he information you have given us th rough the sources available to us, then you must provide proof of the informat ion for us to decide if you are eligible. DES and/or AHCCCS will keep your info rmation for at least 7 years. Do I have to give information about my citizenship and immigration status? $  To get the most help, you need to give us info rmation about citizenship and immigration status for each person who is applying for help. • Giving us the citizenship and immigration status for all people who are eligible for benefits allows us to include them in the Nutrition Assistance and/or Cash Assistance benefit amount. When you do not give us this information, it will not affect the eligibility of the people you are applying for who have given us verification of their citizenship or qualified non-citizen status, but it may affect the amount of the benefits for these people. • If you choose not to give us information regarding immigration status but still want AHCCCS Medical Assistance, you may only be eligible for emergency medical services. • You do not need to give us information about citizenship and immigration status for any person who is not applying. • You do need to give us information on income, resources, or other information for those who have not given us citizenship or immigration status information to complete the application process. • Under federal law, certain non-citizens such as refugees or political asylees may qualify for Medical Assistance, Nutrition Assistance, and/or Cash Assistance. For those non-citizens, United States Citizenship and Immigration Services (USCIS) guidelines state that use of these benefits will not affect your ability to become a Lawful Permanent Resident. • If you are not applying for any benefits or if you chose not to provide citizenship or immigration information, we will not try to find out this information from USCIS. • We will not report you, a family, or a household member to U.S. Immigration and Customs Enforcement (ICE) unless you inform us that you, your family or a household member is in the U.S. illegally. • Households with different immigration statuses may apply for benefits on behalf of US Citizen children and other eligible family members. Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587). FA-001 (11/2016)   Page E   Will I have to do an interview? $ When applying for AHCCCS Medical Assistance and/or help with Medicare cost s, an interview is not needed. When applying for Nutrition Assistance, Cash Assistance, and/or Tuberc ulosis Control you or your representative must complete an interview in person or by phone. If you need special accommodations for an interview, please tell us on page 1 of the application so we can be ready for your interview. How long does it take to find out if I am eligible for benefits after you receive my application? For AHCCCS Medical Assistance an d/or help with Medicare costs, we will make a deci s ion within 45 days.  If you are pregnant, we will make a decision within 20 days.  If you need a disability determination report, we will make a decision within 90 days. For Nutrition Assistance, we will make a decision within 30 days.  If you are eligible for Emergency Nutrition Assistance, we will make a decision within 7 days. $ For Cash Assistance, we will make a decision within 45 days.  If you are a relative or legal guardian applying only for children who are not your own, we will determine if the children qualify within 20 days. How will I know if I am eligible? $  If you are approved for benefits, you will receive a letter explaining the benefits you are eligible for and the amount of benefits you will get.  If you are denied, we will send you a lette r explaining the reason for our decision. How can I get my benefits when my application is approved? If you are approved for AHCCCS Medi cal Assistance and/or help with Medicare costs, you will get an approval letter. You will get your AHCCCS ID card from your enroll ment plan 10 to 14 business days after you get your approval letter. If you need medica l services before you get your AHCCCS ID card, contact your enrollment plan. $ I f you are approved for Nutrition Assistance, Cash Assistance, and/or Tuberculosis Control:  You will get an Electronic Benefit Tr ansfer (EBT) card. This card work s like a debit card. You will get a pamphlet with instructions on how to use your card.  Your benefits are put on your EBT card after approval. It can take up to 48 hours for the benefits to be available. You can call the Customer Service number on the back of the card to check the balance of your benefits.  If you are eligible for Emergency Nutrition Assistan ce, you may get an EBT card at your local DES/FAA office.  If you qualify for Nutrition Assistance benefits, you ca n use the EBT card to buy approved food items. If you qualify for Cash Assistance benefit s, you can use your EBT card to get cash or buy non-food items at any store where EBT cards are ac cepted. You may also withdraw y our Cash Assistance benefits at ATMs, but there may be a fee. Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587). FA-001 (11/2016)   Page F   What is expected of me? $ For all programs:  You must provide DES and/or AHCCCS with the needed information to correctly determine your eligibility and authorize DES and/or AHCCCS to inve stigate and contact any sources necessary to confirm the accuracy of the in formation for your eligibility.  If you are approved for benefits, you will get a le tter telling you what change s you must report. You MUST report your changes timely. $ $ $ Program-specific expectations: If applying for help with AHCCCS Medical Assistance, help with Medicare costs, and/or Cash Assistance, you must take necessary steps to obtain any annuities, pensions, retirement and disability benefits to which you may be entitled, including, but not limited to, Social Security benefits, Railroad retirement, Veterans benefits and unemployment compensation. For AHCCCS Medical Assistance and/or Cash Assistance, you must give us any information you have about an absent parent. If you have reason for not providing this information (such as adoption pending, abuse, incest, neglect, etc.) you may claim good cause. You must cooperate with the Division of Child Support Services (DCSS) to establish paternity, unless you can prove good cause. All adult household members and minor parents who are eligible for Nutrition Assistance and/or Cash Assistance benefits must be fingerprint imaged. Exceptions may apply. For Nutrition Assistance and/or Cash Assistance you must tell us and provide proof to receive deductions, for the following expenses: court ordered child support paid, child/adult dependent care expenses, medical expenses, transportation costs to and from the provider of medical care or daily care of a child/adult dependent, rent or mortgage payments, utility or other shelter costs. What are my rights? $ You have the RIGHT to: • Courteous and professional treatment. • Be treated fairly and equally regardless of race, color, religion, national origin, sex, age, disability, or political beliefs. • Apply for benefits and be given a letter that tells you if you are eligible or not, and/or get a letter before your benefits are reduced or stopped. • Review DES and AHCCCS policy manuals that show the rules and regulations of AHCCCS Medical Assistance, Medicare Savings Program, Nutrition Assistance, Cash Assistance, and Tuberculosis Control if you want to know the reason for our decision. • Talk about your case with a worker or supervisor. • Have all information you give regarding your eligibility kept private according to state and federal law. • Ask for a fair hearing if you disagree with your application being denied, your benefits ended, or are being reduced, or if a decision is not made on your application within the allowable number of days and the delay is due to DES or AHCCCS. • Look at your file before a fair hearing. • Bring an attorney or any other person to a fair hearing. • You have the right to file for Nutrition Assistance benefits separately or at the same time you apply for other programs listed on the application. All Nutrition Assistance applications, regardless of whether they are joint applications or separate applications, must be processed for Nutrition Assistance purposes in accordance with procedural, timeliness, notice and fair hearing requirements. No household shall have its Nutrition Assistance benefits denied solely on the basis that another program applied for has been denied. A separate determination for Nutrition Assistance must be completed. When another program that is applied for is denied a new application for Nutrition Assistance shall not be required. Eligibility shall be determined based on Nutrition Assistance processing time frames from the date the joint application was initially accepted by the State agency. To file a discrimination complaint, contact: U.S. Department of Health and Human Services Director, Office for Civil Rights Room 515-F 200 Independence Avenue, S.W. Washington, DC 20201 1-202-619-0403 (voice) 1-800-537-7697 (TTY) For help filling out the form, you may call: 1-866-632-9992 (Toll- free Customer Service) 1-800-877-8339 (Local or Federal relay) 1-866-377-8642 (Relay voice users) Form: http://www.a scr.usda.gov/complaint_filing_cust.html U.S. Department of Agriculture Director, Office of Adjudication 1400 Independence Avenue, SW Washington, DC 20250-9410 Fax: 1- 202-690-7442 1-800-877-8339 (Local or Federal relay) 1-866-377-8642 (Relay voice users) Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587). FA-001 (11/2016)   Page G   What are the Rules and Penalties? $ If you, your representative, or any household member hides information or gives false information on purpose to get or continue to get Nutrition A ssistance and/or Cash Assistance benef its that you are not entitled to, that person will be subject to:  Criminal Prosecution  Fines  Imprisonment  Other penalties provided for by state and federal laws If you get Nutrition Assistance and/or Cash Assistance, you must follow the rules below:  Do not make false statements or hide information. If you are not truthful, you may have to pay back DES for benefits you receive and you may be taken to court.  Do not do anything dishonest to get benefits that you are not supposed to get.  Do not buy, sell, trade, exchange or ot herwise transfer your or someone el se’s Nutrition Assistance benefits or EBT card.  Do not buy containers with deposits for the purpose of discarding the product and returning the containers to get cash refund deposits.  Do not sell products bought with Nutrition Assistance benefits to exchange them for cash or items other than eligible food.  Do not buy products originally bought with Nutrition Assistance benefits to exchange those products for cash or items other than eligible food.  Do not steal Nutrition Assistan ce or Cash Assistance benefits.  Do not use your Nutrition Assistance benefits to buy non-food items such as alcohol and tobacco.  Do not alter an EBT card.  Do not use someone else’s EBT card unless you are an authorized user approved by DES. If you knowingly break the rules and get Nutrition Assi stance and/or Cash Assi stance benefits, we will disqualify you from getting benefits for:  12 months for the first violation  24 months for the second violation  Permanently for the third violation You or a household member will not be eligible to get Nutrition Assistance and/or Cash Assi stance benefits if you or the household member:  Is a fleeing felon or probation/parole violator.  Has been convicted of using or getting Nutrition Assistance benefits in a transaction involving the sale of firearms, ammunition or explosives. This person can never get Nutrition As sistance benefits again.  Has been found guilty of using or getting Nutrition Assistance benefits in a transaction involving the sale of a controlled substance. This person is not eligible to get Nutrition As sistance benefits for 2 years for the first violation and permanently for the second violation.  Has committed and was convicted of a federal or state felony on or after August 23, 1996 for the possession, use or distribution of a controlled substance.  Has been found by a court of law to have given false i dentification or residence information in order to get benefits in more than one case. This person is not eligible to get benefits for 10 years.  Refuses to sign and comply with t he Personal Respon sibility Agreement (PRA). We give you the PRA during the interview process.  Is an adult recipient (18 years or older) of Ca sh Assistance when any of the following apply: o The recipient does not return the completed I llegal Drug Use Statement. We send the Illegal Drug Use Statement by U.S. Mail afte r Cash Assistance has been approved. o The recipient fails to take a required drug test. o The recipient fails the drug test. You must pay DES back for any Nutrit ion Assistance and/or Cash Assistan ce benefits you received for which your household was not eligible. You can make a re payment agreement. If you do not keep your repayment agreement, we may reduce your Nutrition Assistance and/ or Cash Assistance benefits, take your income tax refunds, or take other legal action, includ ing taking the amounts from your earnings. The following additional penalties apply to the Nutritio n Assistance Program:  An additional disqualification, of up to 18 months, may be ordered by a court.  Any participant or household member who makes false statements or hides information can be fined up to $250,000.00, imprisoned for up to 20 years, or both.  You and/or your household members may be subject to further prosecution under federal laws. Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587). FA-001 (11/2016)   Page H   How to Choose an AHCCCS Health Care Plan: You need to choose a health plan that services your county.  All AHCCCS health plans provide t he same covered medical services.  Review the health plans for your county listed below. American Indians may choose American Indian Health Program or an AHCCCS health plan.  Before you choose a plan, check with your doctor, pharma cy, or hospital to see if they work with the plan that you want. If you want more information about the doctors, specialists, or hospitals that work with a health plan that serves your c ounty, call the number listed below for the health plan. If you do not choose a health plan, one will be assigned to you. If you have been enrolled in an AHCCCS health plan within the past 90 days, you may be enrolled with your previous health plan. Enter the health plan choice on this application. APACHE COUNTY UnitedHealthcare Communit y Plan .................... 1-800-348-4058 Health Choice Arizona ........................................ 1-800-322-8670 American Indian Health Program ...................... .1 -800-654-8713 If your zip code is 85943, you must choose from the health plans listed under Navajo County. COCHISE COUNTY University Family Ca re ....................................... 1-800-582-8686 UnitedHealthcare Communit y Plan .................... 1-800-348-4058 American Indian Health Program ....................... 1-800-654-8713 COCONINO COUNTY UnitedHealthcare Communit y Plan .................... 1-800-348-4058 Health Choice Arizona ........................................ 1-800-322-8670 American Indian Health Program ....................... 1-800-654-8713 If your zip code is 86336 or 86340, you must choose from the health plans listed under Yavapai County. GILA COUNTY Health Choice Arizona ........................................ 1-800-322-8670 University Family Ca re ....................................... 1-800-582-8686 American Indian Health Program ...................... 1-800-654-8713 GRAHAM COUNTY University Family Ca re ....................................... 1-800-582-8686 UnitedHealthcare Community Plan ................... 1-800-348-4058 American Indian Health Program ....................... 1-800-654-8713 If your zip code is 85643, you must choose from the health plans listed under Cochise County. GREENLEE COUNTY University Family Ca re ....................................... 1-800-582-8686 UnitedHealthcare Communit y Plan .................... 1-800-348-4058 American Indian Health Program ....................... 1-800-654-8713 LA PAZ COUNTY UnitedHealthcare Communit y Plan .................... 1-800-348-4058 University Family Ca re ...................................... 1-800-582-8686 American Indian Health Program ....................... 1-800-654-8713 MARICOPA COUNTY Health Net of Arizona ......................................... 1-888-788-4408 Care 1 st Arizona .................................................. 1-866-560-4042 Health Choice Arizona ........................................ 1-800-322-8670 UnitedHealthcare Community Plan ................... 1-800-348-4058 Mercy Care Plan ................................................. 1-800-624-3879 Maricopa Health Plan ......................................... 1-800-582-8686 American Indian Health Program .......................... 602-417-4000 MOHAVE COUNTY UnitedHealthcare Communit y Plan ............... 1-800-348-4058 Health Choice Arizona ................................ ...1-800-322-8670 American Indian Health Program .................. 1-800-654-8713 If your zip code is 86434, you must choose from the health plans listed under Yavapai County. NAVAJO COUNTY UnitedHealthcare Communit y Plan ............... 1-800-348-4058 Health Choice Arizona .................................. 1-800-322-8670 American Indian Health Program .................. 1-800-654-8713 PIMA COUNTY UnitedHealthcare Community Plan .............. 1-800-348-4058 Health Choice Arizona .................................. 1-800-322-8670 Care 1 st Arizona ............................................. 1-866-560-4042 University Family Ca re .................................. 1-800-582-8686 Mercy Care Plan ............................................ 1-800-624-3879 American Indian Health Program .................. 1-800-654-8713 If your zip code is 85645, you must choose from the health plans listed under Santa Cruz County. PINAL COUNTY Health Choice Arizona .................................. 1-800-322-8670 University Family Ca re .................................. 1-800-582-8686 American Indian Health Program .................. 1-800-654-8713 If your zip code is 85242 or 85220, you must choose from the health plans listed under Maricopa County. If your zip code is 85292 you must choose from the health plans listed under Gila County. SANTA CRUZ COUNTY University Family Ca re .................................. 1-800-582-8686 UnitedHealthcare Communit y Plan ............... 1-800-348-4058 American Indian Health Service .................... 1-800-654-8713 YAVAPAI COUNTY UnitedHealthcare Communit y Plan ............... 1-800-348-4058 University Family Ca re .................................. 1-800-582-8686 American Indian Health Program .................. 1-800-654-8713 If your zip code is 85342, 85358 or 85390, you must choose from the health plans listed under Maricopa County. If your zip code is 86351 you must choose from the health plans listed under Coconino County. YUMA COUNTY UnitedHealthcare Communit y Plan ............... 1-800-348-4058 University Family Ca re .................................. 1-800-582-8686 American Indian Health Program .................. 1-800-654-8713 Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587). FA-001 (11/2016) Page 1 Contact Information: $ Tell us how we can contact an adult member of y o ur household. Name (First, Middle, Last): _________________________________________________________________________________________ Home Address:____________________________________ Apt. #: ____ City: ____________________ State: ____ Zip Code: ________ Mailing Address (if different): _________________________ Apt. #: ____ City: ____________________ State: ____ Zip Code: ________ Do you live in a shelter?  Yes  No If ‘Yes,’ what kind of shelter? _______________________________________________ _ Phone Number: _________________________ _ T his number is:  Home  Cell  Work  Message  Other: ___________ Other Phone Number: ____________________ _ T his number is:  Home  Cell  Work  Message  Other: ___________ What is the preferred SPOKEN household language?  English  Spanish  Other: ____________________________________ What is the preferred WRITTEN household language?  English  Spanish  Other: ____________________________________ I would like to get information about this application by: Email:  Yes  No Email address: _____________________ __ _____________________________________________________ Text:  Yes  No Number to text (standard text rates apply): ______________________________________________________ If ‘Yes’ is not marked for Email or Text, all information for this application will be sent via U.S. Mail to the mailing addres s provided . I need the following help with this application (check all that apply):  Reading/understanding this application  Filling out this application  Other: __________________________________  American Sign Language  Braille  Language Interpreter Language: _____________ I need the following accommodations for this application (check all that apply):  Hearing  Speaking  Seeing  Writing  Walking  Other: ______________________________ Authorized Representative: $ This section is OPTIONAL. You may auth o rize someone else to represent you in the applic ation process. DES and/or AHCCCS cannot release any information about yo ur eligibility without your written consent. Representative’s Name: ____________________________________ __________ Is representative your legal guardian?  Yes  No Representative’s Mailing Address: ______________________________________ City: ______________State: ____ Zip Code: ______ Representative’s Phone Number: ____________________ This number is:  Home  Cell  Work  Message  Other: _______ Representative’s Other Phone Number: _______________ This number is:  Home  Cell  Work  Message  Other: _______ What is the representative’ s preferred SPOKEN language?  English  Spanish  Other: _________________________ What is the representative’s preferred WRITTEN language?  English  Spanish  Other: _________________________ My representative would like to get information about this application by: Email:  Yes  No Email address: ___________________________________________________________________________ Text:  Yes  No Number to text (standard text rates apply): _____________________________________________________ If ‘Yes’ is not marked for Email or Text, all information for this application will be sent via U.S. Mail to the mailing addres s provided. By signing below, I, the customer, give permission for the person listed above as my representative to act on my behalf in the process of qualifying me for help with insurance costs, help with Medicare costs, Nutrition Assistance, Cash Assistance, and/or Tuberculosis Control. I, therefore:  Give permission for my representative to complete and sign my application.  Give permission for my representative to provide any documents requested, including personal information.  Give permission to my representative to sign on my behalf to permit other people, businesses, or agencies to give personal information about me to DES and/or AHCCCS, including protected health information needed to determine if I am disabled.  Agree to give information about my personal circumstances to my representative.  Agree to allow my representative to assign all my rights to medical reimbursement claims to AHCCCS on my behalf. By signing below, I, the representative, agree to act on the customer’s behalf. I also agree to:  Provide only truthful and complete information under penalty of perjury.  Fill in and sign needed forms.  Obtain and give to DES and/or AHCCCS all information needed to determine if the customer can qualify for help with healthcare costs, help with Medicare costs, Nutrition Assistance, Cash Assistance, and/or Tuberculosis Control, such as the customer’s Social Security number, income, assets, citizenship, residency, medical insurance, and information about the customer’s spouse, minor children, and parents (if the customer is a minor child).  Tell DES and/or AHCCCS right away if the customer: o Has an increase or decrease in income; o Has an increase or decrease in assets; o Changes ownership of assets, including opening or closing financial accounts; o Has a change in address; or o Has a change in health insurance or the amount of premiums paid. If I am determined eligible, this authorization will stay in effect until I or my representative tells you to stop it. This au thorization will expire when my application for assistance is withdrawn or denied, or when my eligibility ends. However, this authorization will continue during any time while I am contesting my eligibility in an administrative hearing or court proceeding. Signature of Applicant: _______________________________________ Date: _____________________________________________________ Signature of Representative: ________________________________________ Date: __________________________________________________________ Arizona Department of Economic Security Fa mily Assistance Administration (DES/FAA) Arizona Health Care Cost Containment System (AHCCCS) App lication for Benefits For Agency Use Only Date: Group Number: Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587). FA-001 (11/2016) Page 2 Release of Information to Hospitals/Hosp ital Agents/Organizations/Agencies: You may give permission to DES and AHCCCS to release information about applicant eligibility. AHCCCS and DES cannot share any information about applicants without the applicant’s wr itten permission. This section is OPTIONAL. Name of Hospital/Hospital’s Agent/Organization/Agency: _____________________________ ____________________________________ _ Contact Person: __________________________________________________________ Phone Number: _________________________ _ Mailing Address: _______________________________ City: _______ _______________ State: _____________ Zip Code: ____________ I give permission for DES and/or AHCCCS staff to tell the hospital, hospital agent, organization, or agency listed above:  That I have applied for help with insurance costs;  The information or proof needed to see if I can get help with insurance costs; and  If approved for help with insurance costs, the effective date of my eligibility, the redetermination due date, and the categor y of assistance for which I was approved. If denied for help with insurance costs, the reason I was denied. Signature of Applicant: ___________________________________________________________ Date: ____________________________ Access to Electronic Benefit Transfer (EBT) Account: $ This section is OPTIONAL. If you are applying for Nutrition Assistance, Cash Assistance, and/or Tuberculosis Control, you may choose a person, called an Alternate Cardholder, to get your benefits for you. If you need an Alternate Cardholder, choose a person you trust. Remember, lost or stolen benefits will not be replaced. EBT Representative’s Name: _______________________________________ ______ EBT Representative’s Date of Birth: _____________ EBT Representative’s Mailing Address: ________________________ ________ City: _________________ State: ___ Zip Code: ________ EBT Representative’s Phone Number: ____________________________  Home  Cell  Work  Message  Other: __________ EBT Representative’s Other Phone Number: _______________________  Home  Cell  Work  Message  Other: __________ Signature of Applicant: ____________________ __ _______________________________ Date: __________________________________ Someone Who Knows You Well: $ We often need to contact people or orga nizations that can v e rify information to determine your eligibility for public assistance. When we contact these people or organizations we tell them your name, our title and that we work for the Department of Economic Security (DES). We are prohibited by law from telling them any thing about you or about your assistance case. Please provide contact information below. Name of someone who knows you well: ________________________________________Relationship to you: __________________________ Mailing Address: ____________________________________________ _____ City: ________________ State: _____ Zip Code: ________ _ Daytime Phone Number: __________________________________________________________________________________________ _ Name of Landlord: __________________________Are you related to the Landlord?  Yes  No If yes, how?_______________________ Mailing Address: ____________________________________________ _____ City: ________________ State: _____ Zip Code: ________ _ Daytime Phone Number: _________________________________________________________________________________________ Emergency Nutrition Assistance: Is anyone in your household applying for Emergency Nutrition Assistance? If YES : fill out this section. If NO : go to page 3. What is the total amount of income, before deductions, you expect to get this month? $ What is the total amount of cash on hand and money in your checking and savings account? $ What are the total monthly housin g costs (rent or mortgage, taxes, homeowner/rental insurance, etc.)? $ What are the total monthly utility cost s (gas, electric, water, etc.)? $ What is your monthly telephone cost? $ Does anyone receive Tribal Food Distribution?  Yes  No Is anyone a migrant or seasonal farm worker?  Yes  No Did anyone get Nutrition Assistance benefits from any other state? If Yes, who received?_______________________________________ When? __________ State: ____  Yes  No Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587). FA-001 (11/2016) Page 3 Personal Information:   $ Tell us about each person in your househol d, starting with you. See page A for a definition of whom you must include. If you are a representative, tell us about who you are representing and others in the household. Name Last, First M.I. (Include Maiden, Alias, Suffix and other names) Applying for? Relationship to Main Contact (1.) (spouse, child/step child, parent, grandchild, niece/ nephew, legal guardian, other ( please describe) Marital Status (never married, married, divorced, or widowed) Date of Birth Social Security Number (If not applying, optional) Sex (Male or Female) Help with Health Insurance Help with Medicare costs Nutrition Assistance Cash Assistance Tuberculosis Control 1. Main Contact 2. 3. 4. 5. 6. $ Citizenship: Complete ONLY for each person applying. If a person is not applying for benefits, skip this section for that person. For those applying, y ou may need to provide proof of citizenship. Is the MAIN CONTACT a U.S. citizen or U.S. nati onal? See page D for more information.  Yes  No  Choose not to answer If the MAIN CONTACT is NOT a U.S. citiz en, what is his/her immigration status?  Lawful Permanent Resident (LPR)  Lawful Temporary Resident  Non-Immigrant Status  Asylee  Refugee  Conditional Entrant granted before 1980  Other  I do not want to provide  Battered Spouse, Child or Parent  Cuban-Haitian Entrant  Deferred Action Status  Deferred Enforced Departure  Legalization under LIFE Act  Legalization under IRCA Applicant  Order of Supervision  Paroled into United States  Removal/Suspension of Deportation  Registry Applicants  Special Immigrant Juvenile Status Applicant  Temporary Protection Status (TPS)  Victim of Trafficking  Withholding of Deportation  Applican t for Asylum, LPR, TPS, or Withholding Deportation What immigration document does MAIN CONT AC T have? Immigration Document Number: _______________________________ _  Permanent Resident card  I-94  Visa Has MAIN CONTACT lived in the U.S. since August 22, 1996?  Yes   Foreign Passport  None  Other: _________________________________ Is PERSON 2 a U.S. citizen or U.S. national ? See page D for more information.  Yes  No  Choose not to answer If PERSON 2 is NOT a U.S. citizen, wh at is his/her immigration status?  Lawful Permanent Resident (LPR)  Lawful Temporary Resident  Non-Immigrant Status  Asylee  Refugee  Conditional Entrant Granted before 1980  Other  I do not want to provide  Battered Spouse, Child and Parent  Cuban-Haitian Entrant  Deferred Action Status  Deferred Enforced Departure  Legalization under LIFE Act  Legalization under IRCA Applicant  Order of Supervision  Paroled into United States  Removal/Suspension of Deportation  Registry Applicants  Special Immigrant Juvenile Status Applicant  Temporary Protection Status (TPS)  Victim of Trafficking  Withholding of Deportation  Applican t for Asylum, LPR, TPS, or Withholding Deportation What immigration document does PERSON 2 have? Immigration Document Number: _____________________________ _ _ _  Permanent Resident card  I-94  Visa Has PERSON 2 lived in the U.S. since August 22, 1996?  Yes  No  Foreign Passport  None  Other: ________________________________ Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587). FA-001 (11/2016) Page 4 Is PERSON 3 a U.S. citizen or U.S. national? See page D for more information.  Yes  No  Choose not to answer If PERSON 3 is NOT a U.S. citizen, what is his/her immigration status?  Lawful Permanent Resident (LPR)  Lawful Temporary Resident  Non-Immigrant Status  Asylee  Refugee  Conditional Entrant granted before 1980  Other  I do not want to provide  Battered Spouse, Child or Parent  Cuban-Haitian Entrant  Deferred Action Status  Deferred Enforced Departure  Legalization under LIFE Act  Legalization under IRCA Applicant  Order of Supervision  Paroled into United States  Removal/Suspension of Deportation  Registry Applicants  Special Immigrant Juvenile Status Applicant  Temporary Protection Status (TPS)  Victim of Trafficking  Withholding of Deportation  Applicant for Asylum, LPR, TPS, or Withholding Deportation What immigration document does PERSON 3 have? Immigration Document Number: _____________________________ _ _ _  Permanent Resident card  I-94  Visa Has PERSON 3 lived in the U.S. since August 22, 1996?  Yes  No  Foreign Passport  None  Other: _______________________________ Is PERSON 4 a U.S. citizen or U.S. national? S ee page D for more information.  Yes  No  Choose not to answer If PERSON 4 is NOT a U.S. citizen, what is his/her immigration status?  Lawful Permanent Resident (LPR)  Lawful Temporary Resident  Non-Immigrant Status  Asylee  Refugee  Conditional Entrant granted before 1980  Other  I do not want to provide  Battered Spouse, Child or Parent  Cuban-Haitian Entrant  Deferred Action Status  Deferred Enforced Departure  Legalization under LIFE Act  Legalization under IRCA Applicant  Order of Supervision  Paroled into United States  Removal/Suspension of Deportation  Registry Applicants  Special Immigrant Juvenile Status Applicant  Temporary Protection Status (TPS)  Victim of Trafficking  Withholding of Deportation  Applicant for Asylum, LPR, TPS, or Withholding Deportation What immigration document does PERSON 4 have ? Immigration Document Number: _____________________________ _  Permanent Resident card  I-94  Visa Has PERSON 4 lived in the U.S. since August 22, 1996?  Yes   Foreign Passport  None  Other: ____________________________ Is PERSON 5 a U.S. citizen or U.S. national? See page D for more information.  Yes  No  Choose not to answer If PERSON 5 is NOT a U.S. citizen, what is his/her immigration status?  Lawful Permanent Resident (LPR)  Lawful Temporary Resident  Non-Immigrant Status  Asylee  Refugee  Conditional Entrant granted before 1980  Other  I do not want to provide  Battered Spouse, Child or Parent  Cuban-Haitian Entrant  Deferred Action Status  Deferred Enforced Departure  Legalization under LIFE Act  Legalization under IRCA Applicant  Order of Supervision  Paroled into United States  Removal/Suspension of Deportation  Registry Applicants  Special Immigrant Juvenile Status Applicant  Temporary Protection Status (TPS)  Victim of Trafficking  Withholding of Deportation  Applicant for Asylum, LPR, TPS, or Withholding Deportation What immigration document does PERSON 5 have? Immigration Document Number: ________________________________ _  Permanent Resident card  I-94  Visa Has PERSON 5 lived in the U.S. since August 22, 1996?  Yes  N o  Foreign Passport  None  Other: ______________________________ Is PERSON 6 a U.S. citizen or U.S. national? S ee page D for more information.  Yes  No  Choose not to answer If PERSON 6 is NOT a U.S. citizen, what is his/her immigration status?  Lawful Permanent Resident (LPR)  Lawful Temporary Resident  Non-Immigrant Status  Asylee  Refugee  Conditional Entrant granted before 1980  Other  I do not want to provide  Battered Spouse, Child or Parent  Cuban-Haitian Entrant  Deferred Action Status  Deferred Enforced Departure  Legalization under LIFE Act  Legalization under IRCA Applicant  Order of Supervision  Paroled into United States  Removal/Suspension of Deportation  Registry Applicants  Special Immigrant Juvenile Status Applicant  Temporary Protection Status (TPS)  Victim of Trafficking  Withholding of Deportation  Applicant for Asylum, LPR, TPS, or Withholding Deportation What immigration document does PERSON 6 have ? Immigration Document Number: _______________________________ _  Permanent Resident card  I-94  Visa Has PERSON 6 lived in the U.S. since August 22, 1996?  Yes  No  Foreign Passport  None  Other: _____________________________ Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587). FA-001 (11/2016) Page 5 Federal Income Tax Filing: Tell us NEXT YEAR’S tax filing information for everyone applying Main Contact Plan to file Federal income tax return?  Yes  No Filing Status:  Head of Household  Qualifying Widow(er)  Single  Married-Filing Separate Return  Married-Filing Joint Return - spouse’s name: Will claim dependents on own tax return?  Yes  No If yes, list dependents’ names: Claimed as dependent on someone else’s tax return?  Yes  No If yes, name of tax filer claiming this person: Person 2 Plan to file Federal income tax return?  Yes  No Filing Status:  Head of Household  Qualifying Widow(er)  Single  Married-Filing Separate Return  Married-Filing Joint Return - spouse’s name: Will claim dependents on own tax return?  Yes  No If yes, list dependents’ names: Claimed as dependent on someone else’s tax return?  Yes  No If yes, name of tax filer claiming this person: Person 3 Plan to file Federal income tax return?  Yes  No Filing Status:  Head of Household  Qualifying Widow(er)  Single  Married-Filing Separate Return  Married-Filing Joint Return - spouse’s name: Will claim dependents on own tax return?  Yes  No If yes, list dependents’ names: Claimed as dependent on someone else’s tax return?  Yes  No If yes, name of tax filer claiming this person: Person 4 Plan to file Federal income tax return?  Yes  No Filing Status:  Head of Household  Qualifying Widow(er)  Single  Married-Filing Separate Return  Married-Filing Joint Return - spouse’s name: Will claim dependents on own tax return?  Yes  No If yes, list dependents’ names: Claimed as dependent on someone else’s tax return?  Yes  No If yes, name of tax filer claiming this person: Person 5 Plan to file Federal income tax return?  Yes  No Filing Status:  Head of Household  Qualifying Widow(er)  Single  Married-Filing Separate Return  Married-Filing Joint Return - spouse’s name: Will claim dependents on own tax return?  Yes  No If yes, list dependents’ names: Claimed as dependent on someone else’s tax return?  Yes  No If yes, name of tax filer claiming this person: Person 6 Plan to file Federal income tax return?  Yes  No Filing Status:  Head of Household  Qualifying Widow(er)  Single  Married-Filing Separate Return  Married-Filing Joint Return - spouse’s name: Will claim dependents on own tax return?  Yes  No If yes, list dependents’ names: Claimed as dependent on someone else’s tax return?  Yes  No If yes, name of tax filer claiming this person: Food Preparation: Tell us how your household buys and prepares food. Does anyone at your address buy and prepare his/her own food separate from others in the household? If Yes, tell us about the people who buy and prepare their own food:  Yes  No Name (First & Last): Age: Relationship to MAIN CONTACT: Does this person pay expenses? What expenses?  Yes  No  Yes  No  Yes  No  Yes  No Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587). FA-001 (11/2016) Page 6 Prior Medical Expenses: Who? Month(s)? Does anyone applying for benefits also need help with medical bills in any of the last three months?  Yes  No Does anyone in this application have Medicare and want help paying their Medicare Part B premium for any of the last three months?  Yes  No $ Temporary Absence: Tell us about any people who are temporarily li ving outside of your home that are expected to return. Name (First and Last) Date Left Expected Return Date Temporary Address Why are they out of the home? $       Residency for All Applicants: Tell us about residency. You may need to provide proof of residency. Is each person applying for benefits a resident of Arizona?  Yes  No If No, who is not? __________________________________ Did any of the persons applying for benefits move to Arizona within the last four months?  Yes  No If Yes, who? ____________________________________ __ Date moved: _______________ $ Questions for All Applicants: Answer the following questions for anyone who is applying for benefits. Is anyone applying for benefits currently in jail, prison or detention center?  Yes  No If Yes, who? ______________________________________ Is this person currently serving a sentence based on being convicted of a crime?  Yes  No   Expected release date: ___________________ Has anyone applying for benefits been released from a jail, prison or detention center within the last four months?  Yes  No If Yes, who? ______________________________________ Release date: _________________ Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587). FA-001 (11/2016) Page 7 Race If Hispanic/Latino, check ethnicity: Person American Indian or Alaskan Native Asian Indian Black or African American Chinese Filipino Guamanian or Chamorro Japanese Korean Native Hawaiian Other Asian Other Pacific Islander Samoan Vietnamese White Mexican Mexican American Chicano/a Puerto Rican Cuban Other Main Contact Person 2 Person 3 Person 4 Person 5 Person 6 $ American Indian and Alaskan Native Persons: Complete this section if anyone applying is an American Indian or Alaska Native. Person Enrolled in Federally Recognized Tribe Name of Tribe Received services from  Indian Health Service;  a tribal health program;  urban health program; or  through a referral from one of these programs? If no, is the person eligible to receive services?  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No Person Living on a Reservation? Name of Reservation Tribal Census Number  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No  Yes  No $ Race/Ethnicity: Select one or more answers for each person applying for benefits (optional). Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587). FA-001 (11/2016) Page 8 $ Help with Health Insurance Costs, Help with Medicare Costs, and Cash Assistance Questions: Complete this section for anyone who is applying for help with insurance costs and/or help with Medicare costs, and/or Cash Assistance. Is anyone you are applying for pregnant?  Yes  No Who? Number of Babies Due Expected Due Date For anyone applying un der age 19, are both of his/her parents living in the home?  Yes  No If No, complete the information below: Child’s Name Parent’s Name (First, Last) Social Security Num ber Date of Birth Mailing Address City, State Zip Code Phone Number: Reason parent is absent:  Deceased  Out of Home Child’s Name Parent’s Name (First, Last) Social Security Num ber Date of Birth Mailing Address City, State Zip Code Phone Number: Reason parent is absent:  Deceased  Out of Home Child’s Name Parent’s Name (First, Last) Social Security Num ber Date of Birth Mailing Address City, State Zip Code Phone Number: Reason parent is absent:  Deceased  Out of Home Child’s Name Parent’s Name (First, Last) Social Security Num ber Date of Birth Mailing Address City, State Zip Code Phone Number: Reason parent is absent:  Deceased  Out of Home Has anyone ever received Supplemental Security Income (SSI)?  Yes  No Who? ________________________________ Does anyone have Medicare Coverage?  Yes  No Who? ______________ ___________________ Medicare Claim or Railroad Retirement Number ______________________  Part A – Hospital Insurance  Part B – Medical Insurance  Part D – Prescription Drug Plan Who? ______________ ___________________ Medicare Claim or Railroad Retirement Number ______________________  Part A – Hospital Insurance  Part B – Medical Insurance  Part D – Prescription Drug Plan $ Foster Care and Adult with Child: Answer the following questions for anyone who is applying for benefits. Was anyone in Arizona Foster Care on his/her 18 th birthday?  Yes  No Who? _______________________________________ Was anyone in Arizona Tribal Foster Care on his/her 18 th birthday?  Yes  No Who? ______________________________________ What Tribe? _________________________________ Does any adult live with at least one child under age 19 and is the main caretaker of the child?  Yes  No Who? ______________________________________ Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587). FA-001 (11/2016) Page 9 $ Potential Benefits: Tell us about everyone applying to help determine if he/she may be eligible for additional benefits . Has anyone you are applying for, their spouse or deceased spouse, worked for:  A government agency  An employer with a pension plan?  Yes  No If Yes, who? __________________________________ Employer name: _____________________________ Dates of employment: __________________________ Is anyone you are applying for:  A person who served in the U.S military,  The spouse of a person who se rved in the U.S. military,  The widow or widower of a person who serv ed in the U.S. military, or  The child of a person who served in the U.S. military?  Yes  No If Yes, provide the following information: Veteran’s Name:_______________________________ Veteran’s Social Security Number: ____________________________________ Service Serial Number:________________________ Branch of service:______________________________ Veteran’s Date of Birth:________________________ VA Claim Number:_____________________________ Dates of service: ____________________________ $ Expenses: Answer the following questions if anyone in your household is applying for Nutrition Assistance and/or Cash Assistance. Do you or anyone in your household pay for the care of a child or disabled adult in order to work, look for work, attend training o school?  Yes  No If Yes, amount: $ ______________________ ___ _____ Do you or anyone in your household have transportation costs to travel to/from the pers on or agency that provides after school care or adult daycare?  Yes  No Do you or anyone in your household pay court-ordered child support?  Yes  No If Yes, who pays? ____________________ _________ Amount paid: $ _______________________________ How often paid? ________________________ ______ $ Employment: Tell us about everyone’s employment, including self-employment and rental income. You may need to provide proof of income. If self-employed, please attach the most current federal tax forms: 1040, SE and applicable schedules such as C, C-EZ, E, F and K1. If you do not have tax forms, attach proof of business income and expenses for at least the la st and current calendar month. Does ANYONE work?  Yes  No If Yes, give employment information below: Who Employer’s Name and Phone Number: How often paid? Weekly, Biweekly, Semi Monthly, Monthly Gross Earnings Per Pay check and date (before deductions): How many hours worked per week? Did anyone leave a job in the last thirty (30) days?  Yes  No If Yes, who?______________________________ _ _______________ _ Is ANYONE self-employed?  Yes  No Has business been in existence for 12 months?  Yes  No Is more than one person self-employed?  Yes  No Has business been in existence for 12 months?  Yes  No If Yes, amount: $ ______________________________ If Yes, who?_____________________________________________ __ Type of work: ____________________________________________ __ Annual gross income (before business expenses): $_______________ _ Annual business expenses: $ ________________________________ _ If No, date business started: __________________________________ If Yes, who?____________________________________________ ___ Type of work: _____________________________________________ Annual gross income (before business expenses): $________ ________ Annual business expenses: $ ________________________________ If No, date business started: _________________________________ Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587). FA-001 (1 1 /2016) Page 10 $ Other Income: Tell us about other income everyone receives. You may need to provide proof of income. Type of Income: Who Receives? Amount How often received? Who pays the income? Is anyone in the household an owner or member of a franchise, corporation or limited liability corporation? Social Security Benefits Supplemental Security Income (SSI Cash) Retiremen t/pension Unemployment Disability/worker’s compensation Child Support  Court Ordered  Other _____________ Spousal Maintenance (Alimony) Veterans benefits Gifts, contributions or loans Tribal money  Gaming  Other: __________ Rental income Per capita payments from natural resources, usage rights, leases or royalties Payments from natural resources, farming, ranching, fishing, leases or royalties from Indian trust land Money from selling things that have cultural significance Other: ________________________________________ Check here if no other income  $ Expected Income Changes: In the next twelve (12) months, does an yone in the household expect income changes because of seasonal wo rk or contract employment? Please tell us only about the changes that happen regularly.  Yes  No If Yes, who? _______________________ _ _ _ How many sources are expected to change? ____________ _ Name of sources _________________________________ __ Amount expected to make in the next 12 months $_____________________________________________ _ _ _ Does anyone in the household expect changes in income for any other reason in the next twelve (12) months?  Yes  No If Yes, who?__________________________________ __ Please explain: Allowed deductions from taxes/income: Tell us if anyone has the following expenses that can be taken for taxes. Do not include self-employment expenses. Expense Who has the expense? Amount How Often? Deductions from pay for expenses like retirement and insurance taken out before taxes Student Loan Interest Spousal Maintenance (Alimony) Other (Type) ________________ __ ______________________ Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587). FA-001 (11/2016) Page 11 $ Questions for All Applicants: Answer the following questions for everyone who is applying for benefits. Is any adult you are applying for not able to work because of a medical or mental condition that has lasted or may last 12 months, or might result in death?  Yes  No If Yes, who?_______________________________ Date of last day worked?_____________________ Expected return date:________________________ Does any child you are applying for have a physical or mental condition that is disabl ing and has lasted or may last 12 months, or result in death?  Yes  No If Yes, who? ______________________________ When did the condition begin? ________________ Is anyone you are applying for under age 65, have a disability expected to last at least 12 months and is working?  Yes  No Does anyone you are applying for need help with activities of daily living (bathing, dressing, etc.) through personal assistance, services, nursing home, or other medical facility?  Yes  No Does anyone you are applying for have a legal guardian?  Yes No Name of legal guardian:______________________ $ Nutrition Assistance and Cash Assistance: Answer these questions for anyone who is applying for Nutrition Assistance and/or Cash Assistance. Is anyone you are applying for a migrant or seasonal farm worker? Is this person under contract/agreement to begin employment within 30 days? Is this person working a minimum of 30 hours a week?  Yes  No  Yes  No  Yes  No If Yes, farm worker type:__________________ $ Nutrition Assistance and Cash Assistance Questions: Answer these questions if the MAIN CONTACT is applying for Nutrition Assistance and/or Cash Assistance. Everyone may still be able to get benefits if he/she has a felony drug conviction. See page G for more information. Has anyone you are applying for been determined to be blind or have a disability by:  the Social Security Administration (SSA), or  the Veterans Administration (VA)?  Yes  No If Yes, who? _________________________ Has anyone you are applying for had a felony conviction for possession, use, or distribution of a controlled substance on or after August 23, 1996?  Yes  No City/state of conviction: _________________ Date of conviction: _____________________ Type of conviction:_____________________ Is anyone you are applying for:  Running from the law on any felony charges, or  In violation of probation or parole?  Yes  No If Yes, who? _________________________ Has anyone been found to have committed a Nutrition Assistance and/or Cash Assistance Intentional Program Violation in Arizona or any other state?  Yes  No __ If Yes, who? _________________________ What state?__________________________ ___ Are you or anyone you are applying for on strike?  Yes  No If Yes, who: ____________________________ Are you or anyone you are applying for a boarder?  Yes No If Yes, who? __________ _________________ ____ If Yes, who? _______________________________ If Yes, who? _______________________________ If Yes, who? _______________________________ Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587). FA-001 (10/2016) Page 12 $ Questions for All Applicants: Answer the following questions for everyone who is applying for benefits. Is anyone on this application attending school?  Yes  No If Yes, complete grid below: $ Expenses: Answer the following questions if anyone in your household is applying for Nutrition Assistance and/or Cash Assistance. Are you living in HUD housing?  Yes  No Amount $_____________________ What are your monthly housing costs for: Rent $_____________ , Mortgage $________________ , Taxes $_______________, Homeowner/rental insurance $_______________, Other $______________________. What are the total monthly utility costs for: Gas $___ ______, Electric $____________, Water $___________, Other $___________ Are the persons you are applying for living in government-assisted housing?  Yes  No Are the persons you are applying for homeless?  Yes  No $ Other Bene fits and Expenses: Answer the following questions about rece iving benefits from other states and expenses for anyone disabled or over age 60. Has anyone on the application received Nutrition Assistance from another state?  Yes  No Has anyone on the application re ceived Cash Assistance benefits from another state?  Yes  No Is anyone on the application living in an assisted living facility or group home ?  Yes  No If Yes, who? ________________________________ Is anyone disabled or over age 60, does he/she have any paid or unpaid medical expenses, even if he/she has medical insurance (example: travel expenses to and from medical provider, doctor visits, prescriptions, lab work, etc.)?  Yes  No If Yes, who?________________________________ _ Average Total Monthly Medical Expenses $____________________________________ $ Cash Assistance Questions: Answer these questions for everyone who is under age 19 and applying for Cash Assistance. Do all children you are applying for who are under the age of 19 have current immunizations (shots)?  Yes  No If No, who does not? ___________________________ ____________________________________________________________ Has anyone you are applying for received Cash Assistance this month?  Yes  No If Yes, who? __________________________ _ ______ _ When did benefits stop? ___________________ _ ___ _ Name of city/state: ____________________________ What type of benefits?_________________________ Who Name of School Address Full/Part Time Grade Level Start Date Graduation date If Yes, who? ________________________________ What type of benefits? ________________________ When did benefits stop? ______________________ Name of state/county: ________________________ If Yes, who? ________________________________ When did benefits stop? ______________________ Name of state/county: ________________________ Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587). FA-001 (11/2016) Page 13 $ Resources: Answer the following questions if anyone in your ho usehold is applying for Nutrition Assistance and/or Cash Assistance. Does anyone you are applying for have any type of bank account?  Yes  No If Yes, total value: $_________________________________ Who owns? _______________________________________ If Yes, total value: $ ________________________________ Who owns? _______________________________________ Does anyone you are applying for have any:  Cash  Uncashed checks  Money on a pre-paid debit card  Yes  No If Yes, total value: $_________________________________ Does anyone you are applying for have any:  Retirement account  Annuity  Yes  No If Yes, total value: $_________________________________ Who owns? _______________________________________ Name of financial institution:__________________________ If Yes, total value: $_________________________________ Who owns? _______________________________________ Name of financial institution:___________________________ Do you or anyone in your household own or have their name on:  stock  bond  money market account,  Certificates of Deposit (CDs)  trust funds  life insurance  Yes  No If Yes, total value: $_________________________________ Who owns? _______________________________________ Name of financial institution:__________________________ If Yes, total value: $_________________________________ Who owns? _______________________________________ Name of financial institution:__________________________ Does anyone you are applying for own the home where they live?  Yes  No If Yes, total value: $_________________________________ Who owns? _______________________________________ Where? __________________________________________ Does anyone you are applying for own any vehicles? (cars, trucks, boats, RVs, etc.)  Yes  No If Yes, total value: $_________________________________ Who owns? _______________________________________ How many vehicles? ________________________________ Does anyone you are applying for own any other land or buildings anywhere?  Yes  No If Yes, total value: $_________________________________ Who owns? __________________________ _ ___________ Where? ___________________________________________ $ No Income: If no one has income, explain how you pay your bills below:  Living with friends  Using money from savi ng s or checking accounts  Living off credit cards  Working odd jobs Monthly income: $_____________  Other________________________________ Are you:  Getting loans from people  Someone is giving me money  Someone is paying bills directly  Working in exchange for rent If Yes, complete grid below: Name of person helping: _____________________ Telephone number: _________________________ Email: ___________________________________ If loan, amount: $__________ When does it need to be paid back? _________________ If gift, amount: $__________________________ If paying bills, which ones? ____________________ If working in exchange, amount of rent: $________________ Medical As sistance Questions: Answer the following questions for everyone applying for help with health insurance costs and/or help with Medicare costs. Do any applicants have an injury or illness due to an accident or medical malpractice?  Yes  No If Yes, who? __________________________________ Are any applicants currently admitted to a hospital?  Yes  No If Yes, who? __________________________________ Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587). FA-001 (11/2016) Page 14 $ Health Insurance Coverage: Answer the following questions if anyone in your household is applying for help with health insurance costs, help with Medi care costs, and/or Cash Assistance. Do any applicants have health insurance other than AHCCCS or Medicare? If ‘Yes,’ give the following information:  Yes  No Name of Insured Name of Insurance Provide r Policy Numbe r Coverage Effective Date Does any child under age 19 in this application qualify for health benefits (even if they choose not to enroll) through the State of Arizona because:  A parent or step parent (in or out of the home) works for an employ er (State or other public agency) that offers health insurance coverage through the State of Arizona and is eligible to get health insurance coverage; or  The child or child’s spouse works for an employer (State or other public age ncy) that offers health insurance cove rage through the State of Arizon a and is eligible to get health insurance coverage?  Yes  No If Yes, who?__________________ Have any children under the age of 19 lost health insurance coverage in the last 90 days? If ‘Yes,’ give the following information:  Yes  No If YES, name of child(ren) who lost health insurance coverage: Name of Policy Holder Name of Insurance Company Group Number Policy Number Insurance Company Phone Number Coverage End Date Why did the health insurance coverage stop?  Cost too much  Coverage was through Medicaid/CHIP, or through Advance Prem ium Tax Credits (APTC), or Cost Sharing Reductions  Divorce or death of parent  Employer stopped offering coverage for dependents  Job changed or ended  Other: ___________________________________ If the health insurance cost too much:  The monthly premium to cover one person is: $_____________________  The monthly premium to cover the family is: $_____________________  Was approved for APTC because employer-sponsored insurance was determined to be unaffordable. Do any children under the age of 19 you are applying for have a chronic illness? (Medical conditio n that requires frequent and ongoing treatment and that if not properly treated will seriously affect the person’s overall health).  Yes  No If Yes, who? _________________________________ _ Health Plan Choice: Please see page H for enrollment plan choices for everyone applying for Medical Assistance. Name Health Plan Choice Person 1 Person 2 Person 3 Person 4 Person 5 Person 6 Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587). Page 15 Health Insurance Tax Credits: If you are not eligible for help with health insurance cost, you may be eligible for federal tax credits to help with your heal th insurance premiums . If you are not eligible for any programs through AHCCCS, we will send your information to the federal Health Insurance Marketplace to see about health insurance tax credits. Insurance from Jobs: Tell us about health insurance that may be offered through a job. Is anyone eligible for health insurance coverage offered by an employer, or will you become eligible for coverage in the next 60 days?  Yes  No  I do not know If YES: answer the questions below. If NO or I DO NOT KNOW : go to the next page. Tell us about the job that offers health insurance covera ge . If there are plans offered by more than one employer and you need more space, please attach additional pages. If you need help with the information, contact the employer. Employee Name: ___________________________________________ Employee Social Security Number: _______________________ _ Employer Name: ___________________________________________ Em ployer Identification Number (EIN): _____________________ _ Employer Address: __________________________________ City: __________________ State: __________ Zip Code: ____________ _ Whom may we contact about employment health insurance cove rage at this job?_____________________________________________ If you are in a waiting or probationary period for insurance offered by an employer, when can you enroll in coverage? ____________________________________________________________________________ Who is eligible for coverage from this job? __________________________________________________________________________ Does the employer offer a health plan that m eets the minimum value standard*?  Yes  No  I do not know If YES: answer the questions below. If NO or I DO NOT KNOW: go to the next page. *An employe r -sponsored health plan meets “minimum value standard” if the plan’s share of the total allowed benefit costs covered by the pla n is no less than 60% of such costs. For the lowest-cost plan that meets the minimum value standard* offered only to the employee (do not include family plans): If the employer has wellness programs, prov ide the premium that the emplo yee would pay if he/she received the maximum discount for any tobacco cessation programs, and did not receive any other discounts based on wellness programs: How much will the employee have to pay in premiums for that plan? $ __________________________________  I do not know How often wil l the employee have to pay the premium?  Weekly  Twice a month  Every 2 Weeks  Monthly  Quarterly  Yearly  I do not know  Other: _____ What changes will the employer make for the new plan year (if known)?  Employer will not offer health coverage  Employer will start offering health coverage to employees or c hange the premium for the lowest-cost plan available only to the employee that meets the minimum value standard*. How much will the employee have to pay in premiums for that plan? $ __________________________________  I do not know How often will the employee have to pay the premium?  Weekly  Twice a month  Every 2 Weeks  Monthly  Quarterly  Yearly  I do not know  Other: ______  I do not know Renewal of Tax Credit Coverage in Future Years: To make it easier for the Federal Fa c ilitated Marketplace to det ermine my eligibility for help paying for health coverage in fu ture years, I agree to allow the Marketplace to use income data, including in formation from tax returns. The Marketplace will send me a noti ce, let me make changes, and I can opt out at any time. Yes, renew my eligibility for the next:  5 years  4 years  3 years  2 years  1 year No, do not use information from tax returns to renew my coverage  Go to the next page to sign the application. FA-001 (11/2016) Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587). Page 16 Sign the Application: $ The application is not valid until it is sign ed. All unrelated adults without a ch ild in common must sign the application. Otherwise, the application must be signed by one of the following:  The applicant or the applicant’s designee (we must have do cumentation showing this person is authorized to act on the applicant’s behalf); or  The applicant’s spouse, if married and living within the same household; or  The parent/legal guardian of a minor child. Penalty Warning The information provided on this form may be verified by federal, state, and local officials. If any information is inaccurate , you may be denied benefits.  You must not knowingly withhold or give false information with the intent to receive or to continue receiving DES and/or AHCCC S benefits to which you are not entitled.  You will be required to pay back to DES and/or AHCCCS any benefits you receive as a result of withholding or giving false info rmation and you will be subject to criminal prosecution.  It is fraud for any person to knowingly withhold information with the intent to receive or continue to receive benefits to whi ch he/she is not eligible. Any person found guilty of fraud may be subject to fines , criminal prosecution, imprisonment or other penalties as provided for by applicable State and Federal laws. Release of Information I authorize DES and/or AHCCCS to investigate and contact any source s necessary to establish eligibility and the accuracy of fin ancial information that pertains to AHCCCS eligibility. Assignment of Rights to Other Benefits for Medical Care I understand that if I am or members of my household are appro ved for DES and/or AHCCCS benefits, DES and/or AHCCCS can collect payment from any other parties who may be responsible for paying for my/our health costs. This includes:  Private or employer-sponsored health insurance (not including Medicare)  Persons, such as an absent spouse or parent, who ar e legally responsible for providing medical support  Private or employer-spons ored disability insurance  Private or employer-sponsored accident insurance  Insurance claims, jury awards, or legal settlements resulting from injuries I understand that DES and/or AHCCCS cannot collect more than the co sts paid by DES and/or AHCCCS. I also understand that I mus t give information about other responsible parties and take any action needed to receive medical support. This includes es tablishing paternity of my ch ildren, unless I can prove good cause not to do so. I understand that DES and/or AHCCCS and/or their contractors will re lease informati on to DES/Division of Child Support Services (DCSS), for a parent of a child who does n ot live in the home and the child has AHCCCS or pr ivate health insurance. DCSS may use this information to get a medical support order. Assignment of Rights to Other Benefits for Cash Assistance State and federal law (A.R.S. 46-407) provide that the legal rights to child support and spousal maintenance must be assigned t o the State of Arizona for all persons receiving Cash Assistance. I understand:  While receiving Cash Assistance, the State has the right to keep child support or spousal ma intenance collections, including s upport or spousal maintenance that was owed while Cash Assistance was paid.  When Cash Assistance stops, current support payments will be paid to me. The state may continue to collect any assigned back p ayments for support (assigned arrears) owed before and during the time I received Cash Assistance.  Child support payments will be used to pay back the state for Cash Assistance paid to me or anyone on my application.  The State will not keep more from my collected current support or assigned arrears than the total amount of Cash Assistance I received.  Also the State will not keep any arrears that are more than the total amount of Cash Assistance I received. Declarations and Statement of Truth By signing this application:  I agree I have read and understand the rules and penalties on pag e G included with the application. I have read and understan d my rights and responsibilities, and provided Social Secu rity numbers for each applicant that has a Social Security number.  I agree I have read and understand the assignment or rights to other benefits for Medical Care above.  I agree I have read and understand the assignment of support rights for Cash Assistance above.  I agree that certain Nutrition Assistance and/or Cash Assistanc e household members will cooperate with the work programs, whic h includes looking for work and accepting training and/or a job. If anyone does not, or will not, look for work, attend training, or accept a job, my benef its may be reduced or stopped.  I agree to cooperate with Arizona or Federal personnel in the completion of a quality control review on my eligibility for ben efits.  In the event DES or its agents engage in child support enforcement activities involving me, I understand the Assistant Attorne ys General and Deputy County Attorneys handling the cases represent DES, and not me or my children.  If my child support case goes to court, I understand certain per sonal information contained in this application or my DES reco rds may be released to the court and other parties to the case and becomes a public record document.  I also hereby agree to accept service of process by first class mail with regard to any paternity or child support proceeding initiated by DES and its agents.  I understand that my records will be kept confidential and will only be released for purposes authorized by federal and state law.  I understand that I may be required to pay a premium if enrolled in the KidsCare or Freedom to Work program. I swear under penalty of perjury that the statements and documents provided about myself and persons in my home, that relates t o my eligibility for benefits, is true and correct to the best of my knowledge, and that I have not withheld any information. I swear under penalty of perjury t hat any photocopied information I have provided are the same as the original documents. Signature of Applicant: ________________________________________________________________________ Signature of Spouse: _________________________________________________________________________ Signature of Other Adult in Household: ___________________________________________________________ Signature of Authorized Representative: ____________________________________________________________ Signature of Witness (if signed with mark): ________________________________________________________ Date: _____ ____________________ Date: _________________________ Date: _________ _________ _______ Date: _________________________ Date: _________________________ FA-001 (11/2016) Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587). FA-001 (11/2016) Page 17 Voter Registration: $ Tell us if any person over the age of 18 listed on this application would like to register to vote. If you are not registered to vote where you live now, would you like to apply to register to vote here today? Please go to the last attached page of this application, whic h is the “Offer of Voter Registration” form . Read the information, check “Yes” or “ No”, and then sign and date the form where indicated. Applying to register or declining to register to vote will not affect the amount of assistance that you will be provided by thi s agency. If you do not check either box, you will be considered to have decided not to re gister to vote at this time. If you would like help in filling out the vote r registration application form, we will he lp you. The decision whether to seek o r accept help is yours. You may fill out the application form in private. If you believe that someone has interfered with your right to register or to decline to register to vote, y our right to privacy in deciding whether to register to vote, or your right to choose y our own political party or other political preference, you may f ile a complaint with the State Election Director, Secretary of State’s Office, 1700 West Washington, Phoenix, AZ 85007, 602-542-8683 . You may also get a voter registration form at www.azsos.gov/election/ voterinformation.htm . Arizona Department of Economic Security Family Assistance Administration P.O. Box 19009 Phoenix, Arizona 85005-9009 If any additional information is needed, you will be contacted. You will be notified of our decision. This institution is prohibited from discriminating on t he basis of race, colo r, national origin, disability, age, sex and in so me cases religion or political beliefs. The U.S Department of Agriculture also prohibits discrimination against its customers, employees, and applicants for employment on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status , familial or parental status , sexual orientation, or all or part of an individual ’s income is derived from any public assistance progr am, or protected genetic information in em ployment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all prog rams and/or employment activities.) If you wish to file a Civil Rights program comp laint of discrimination with USDA, complete the USDA Program Discrimination Complaint Form , found online at http://www.ascr.usda.gov/com plaint_filing_cust.html, or at any USDA office, or call (866) 632-9992 to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax (202) 690-7442 or email at [email protected]. Submit the Application: $ Submit your completed and signed applicatio n along with any supporting documents to the: Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587). FA-001 (11/2016) Page 18 Individuals who are deaf, hard of hearing or have speech dis abilities may contact USDA through the Federal Relay Service at (800) 877-8339; or (800) 845-6136 (Spanish). For any other information dealing with Supplemental Nutriti on Assistance Program (SNAP) issues, persons should either contact the USDA SNAP Hotline Number at (800) 221-5689, which is also in Spanish, or call the State Information/Hotline Numbers line (the listing of hotline numbe rs by State can be found online at http://www.fns.usda.gov/snap/cont act_info/hotlines.htm). To file a complaint of discrimination regarding a pro g ram receiving Federal financial assistance through the U.S. Department of Health and Human Services (HHS), write: HHS Director, Office for Civil Rights, Room 515-F, 200 Independence Avenue, S.W., Washington, D.C. 20201 or call (202) 61 9-0403 (voice) or (800) 537-7697 (TTY). USDA an d HHS are equal opportuni ty providers and employers. Equal Opportunity Employer/Program • Under Titles VI and V II of the Civil Rights Act of 1964 (Title VI & VII), and the Americans with Disabilities Act of 1990 (A DA), Section 504 of the Rehabilitation Ac t of 1973, the Age Discrimination Act of 1975, and Title II of the Genetic Information Nondiscrimination Act (GINA) of 2008; the Department prohibits discrimination in admissions, programs, services, activities, or employment bas ed on race, color, religion, sex, national origin, age, disability, genetics and retaliation. The Department must make a reasonabl e accommodation to allow a person with a disability to take part in a program, service or activity. For example, this m eans if necessary, the Department must provide sign language interpreters for people who are deaf, a wheelchair accessible loca tion, or enlarged print materials. It also means that the Department will take any other reasonable action that allows you to take part in and understand a program or activity, including making reasonable changes to an activity. If you believe that you will not be able to understand or take part in a program or activity because of your disability, please let us know of your disability needs in advance if at all possible. To request this document in alternative format or for further in formation about this policy, contact your local office manage TTY/TDD Services: 7-1-1. • Free language as sistance for DES services is available upon request. • Disponible en español en línea o en la oficina local. Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587). FA-001 (11/2016) Page 19 NOTICE OF NON-DISCRIMINATION The Arizona Health Care Cost Containment System (AHCCC S) complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, na tional origin, age, disabili ty, or sex. AHCCCS does not exclude people or treat them differently because of race, color, national origin, age, disability, or sex. AHCCCS provides free aids and services to pe ople with disabilities to communicate e ffectively with us, such as qualified sign language interpreters and written information in other formats (large print, audio, accessible electronic formats, and other formats). AHCCCS provides free langua ge services to people whos e primary language is not English, such as qualified interpreters and information wr itten in other languages. If you need these services, contact the Health-e-Arizona Plus Cu stomer Support Cent er at 1-855-432-7587   ( TTY: 711). If you believe that AHCCCS failed to provi de these services or discriminated in another way on the basis of race, color, national origin, age, disabili ty, or sex, you can file a grievance w ith the AHCCCS General Counsel. You can file a grievance in person or by mail, fax, or email . Your grievance must be in writing and must be submitted within 180 days of the date that the person filing the grievance becomes aware of what is believed to be discrimination. Submit your grievance to:   General Counsel, AHCCCS Administration, Office of Administrative Legal Services, MD 6200, 701 E. Jefferson, Phoenix, AZ 85034 Fax: 602 253 9115 Email: [email protected]. You can al so file a civil rights complaint with the U.S. Department of Health and Human Services, Office for Civil Rights, electronically through the Office for Civil Rights Complaint Portal, available at https://ocrportal.hhs.gov/oc r/portal/lobby.jsf, or by mail at U.S. Department of Health and Human Services; 200 Independence Avenue, SW; Room 509F , HHH Building; Washington, D.C. 20201; or by phone: 1- 800-368-1019, 800-537-7697 (TDD). Complain t forms are available at http://www.hhs.gov/ocr/office/file/index.html. AVISO DE NO DISCRIMINACIÓN Arizona Health Care Cost Containment System (AHCCCS) cumple con las leyes federales de derechos civiles aplicables y no discrimina por motivos de raza, colo r, nacionalidad, edad, dis capacidad o sexo. AHCCCS no excluye a las personas ni las trata de forma diferente debido a su origen étnico, color, nacionalidad, edad, discapacidad o sexo. AHCCCS proporciona as istencia y servicios gratuitos a las personas con discapacidades para que se comuniquen de manera eficaz con nosotros, co mo los siguientes intérpre tes de lenguaje de señas capacitados y información escrita en otros formatos (letra grande, audio, formatos electrónicos accesibles, y otros formatos). AHCCCS proporciona servicios lingüísticos gratuitos a personas cuya lengua materna no es el inglés, como los siguientes intérpretes capac itados y información escrita en otros idiomas. Si necesita recibir estos servicios, comuníquese con Health-e-Arizona Plus Customer Support Center at 1-855-432-7587 (TTY: 711). Si considera que AHCCCS no le proporcionó estos servicios o lo discriminó de ot ra manera por motivos de origen étnico, color, nacionalidad, edad, discapacidad o sexo, puede presentar un r eclamo a AHCCCS General Counsel. Puede presentar el reclamo en persona o por correo postal, fax o correo electrónico. Su querella deberá presentarse por escrito en plazo de 180 días a partir de la fecha en la que la persona qu e se querelle se percate de lo que le parezca ser discrimen. Remita su querella a: General Counsel, AHCCCS Administration, Office of Administrative Legal Services, MD 6200,701 E. Jefferson, Phoenix, AZ 85034 o envíela por fax a: 602 253 9115 0 envíela por correo electrónico (Email) a: Equa [email protected]. También puede presentar un reclamo de derechos civiles ante la Office for Civil Rights (O ficina de Derechos Civiles) del Depa rtment of Health and Human Services (Departamento de Salud y Servicios Humanos) de EE. UU. de manera electrónica a través de Office for Civil Rights Complaint Portal, disponible en https://ocrportal .hhs.gov/ocr/portal/lobby.jsf, o bien, por correo postal a la siguiente dirección o por teléfono a los números que figur an a continuación: U.S. Department of Health and Human Services; 200 Independence Avenue, SW; Ro om 509F, HHH Building;Washington, D.C. 20201;1-800- 368-1019, 800-537-7697 (TDD). Puede obtener los fo rmularios de reclamo en el sitio web http://www.hhs.gov/ocr/office/file/index.html . Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587). FA-001 (11/2016) Page 20 ATENCIÓN: si habla español, tiene a su disposición servicio s gratuitos de asistenc ia lingüística. Llame al 1-855-432-7587 (TTY: 711). 注意：如果您使用繁體中文，您可以免費獲得語言援助服務。請致電 1-855-432-7587 （ TTY ： 711 ）。 CHÚ Ý: N ếu bạ n nói Ti ếng Vi ệt, có các d ịch v ụ hỗ trợ ngôn ng ữ miễn phí dành cho bạ n. G ọi s ố 1-855- 432-7587 (TTY:711). م : لحوظة تتحدث كنت إذا العربية . بالمجان لك تتوافر اللغوية المساعدة خدمات فإن ، برقم اتصل 1- 885-432-7587 الصم ھاتف رقم ) : والبكم 711.(   PAUNAWA: Kung nagsasalita ka ng T agalog, maaari kang gumam it ng mga serbisyo ng tulong sa wika nang walang bayad. Tumawag sa 1-855-432-7587 (TTY:711). 주의 : 한국어를 사용하시는 경우 , 언어 지원 서비스를 무료로 이용하실 수 있습니다 . 1-855-432-7587 (TTY: 711) 번으로 전화해 주십시오 . ATTENTION : Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement. Appelez le 1-855-432-7587 (ATS : 711). ACHTUNG: Wenn Sie Deutsch spre chen, stehen Ihnen kostenlos sprachliche Hilfsdienstleistungen zur Verfügung. Rufnummer: 1-855-432-7587 (TTY: 711). ВНИМАНИЕ : Если вы говорите на русском языке , то вам доступны бесплатные услуги перевода . Звоните 1-855-432-7587 (телетайп : 711). 注意事項：日本語を話される場合、無料の言語支援をご利用いただけます。 1-855-432-7587 （ TTY: 711 ）まで、お電話にてご連絡ください。 OBAVJEŠTENJE: Ako govorite srpsko-hrvatski, usluge jezi čke pomo ći dostupne su vam besplatno. Nazovite 1-855-432-7587 (TTY- Telefon za osobe sa ošte ćenim govorom ili sluhom: 711). : ܐ ܵ ܪ ܵ ܗ ܼ ܙܘ   . ܬ ܼ ܐܝ ܵ ܢ ܵ ܓ ܿ ܼ ܡ ܐ ܵ ܢ ܵ ܫ ܸ ܒܠ ܐ ܵ ܪܬ ܿ ܼ ܝ ܿ ܼ ܕܗ ܐ ܹ ܬ ܿ ܼ ܠܡ ܸ ܚ ܢ ܿ ܬܘ ܼ ܒܠܝ ܿ ܼ ܕܩ ܢ ܿ ܬܘ ܼ ܨܝ ܵ ܡ ܐ، ܵ ܝ ܵ ܪ ܿ ܬܘ ܵ ܐ ܐ ܵ ܢ ܵ ܫ ܸ ܠ ܢ ܿ ܬܘ ܼ ܡܝ ܸ ܡܙ ܿ ܼ ܗ ܐ ܹ ܟ ܢ ܿ ܚܬܘ ܿ ܼ ܐ ܢ ܹ ܐ   ܠ ܿ ܼ ܥ ܢ ܿ ܩܪܘ ܐ ܵ ܢ ܵ ܢܝ ܸ ܡ 711   1 ‐ 855 ‐ 432 ‐ 7587   (TTY:   .(( เรียน : ถ้ าคุ ณพู ดภาษาไทยค ุ ณสามารถใช ้บริการช่วยเหลื อทางภาษาได้ฟรี โทร 1-855-432-7587 (TTY:711). ATTENZIONE: In caso la lingua parlata sia l'italiano, sono disponibili servizi di assistenza linguistica gratuiti. Chiamare il numero 1-855-432-7587 (TTY: 711). Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587). FAA-001 (11/2016) Page 21 OFFER   OF   VOTER   REGISTRATION   FORM   The   Offer   of   Voter   Registration   form   is   the   next   (last)   sheet.    Please   read   it,   answer   “Yes”   or   “No”,   sign   where   it   says   “Signature   of   Client”,   and   date   it.   Do you need help with this application? Visit www.healthearizonaplus.gov or call 1-855-HEA-PLUS (432-7587). NVRA-5 (English) OFFER OF VOTER REGISTRATION Applying to register to vote or declining to regist er to vote will not affect the amount of assistance that you will be provided by this agency. If you are not registered to vote where you live now, would you like to apply to register to vote today? Yes No IF YOU DO NOT MARK EITHER BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO REGISTER TO VOTE AT THIS TIME. If you would like help filling out the vote r registration applic ation form, we will help you. The decision whether to seek or accept help is yours. You may fill out the application form in private. You may take the form with you and mail it to the county recorder yourself or you may comp lete the registration here and deposit it in the box provided. If you choose to register to vote here, the information regarding the agency where the registration took place will remain conf idential and will be used only for voter registration purposes. If you choose not to register to vote at this time, that information will remain confidential and will be used only for voter registration purposes. Signature of Client (or initials of staff person) Date If you believe that someone has interfered with your right to register to vote or to decline to register to vote, your right to privacy in deciding whether to register to vote or in applying to register to vote, or your right to choose your own political party or other political preference , you may file a complaint with: State Election Director Secretary of State’ s Office 1700 West Washington Phoenix, Arizona 85007 (602) 542-8683 FA-001 (11/2016) NVRA-5 (Spanish) PROPOSICIÓN DE EMPADRONAMIENTO La cantidad de ayuda que esta oficina le va a proveer no será afectada por su decisión de empadronarse para votar o de no empadronarse para votar. Si usted no esta empadronado para votar donde uste d actualment e vive, ¿le conviniera solicitar empadronamiento para votar hoy día aquí mismo? Si No SI USTED NO MARCA NINGUNA DE LAS RESPUESTAS, SE CONSIDERAR Á QU E USTED HIZO LA DECISIÓN DE NO EMPADRONARSE PARA VOTAR HOY DÍA. Si usted necesita ayuda para comple tar el formulario de solictud de empadronamiento, nosotro s estamos disp uestos a ayudarle. La decisión de procurar o aceptar ayuda es suya. Se le permite completar el formulario de solicitud en privado. Usted tiene la opci ón de llevarse el formulario consigo y regresarlo por correo al registrador de l condado o usted puede completar su empadronamiento aquí y depositarlo en el depósito que se proporciona. Si usted se decide a empadronarse para votar, la in formación tocante la oficina donde se efectuó el empadr onamiento perman ecerá c onfidencial y se usará únicamente para los propósitos de empadronamiento de votantes. Firma del Cliente (o iniciales del miembro del personal) Fecha Si usted cree que alguien se ha impedi do con su derecho de empadronarse para votar o de no empadronarse para votar, su derecho a privacidad en decidiendo de empadronarse o en solicita r empadronamiento para votar, o su derecho de seleccionar su propio partido político u otra preferencia política, usted puede entablar su queja con: State Election Director Se cretary of State’ s Office 1700 West Washington Phoenix, Arizona 85007 (602) 542-8683