AHCCCS Application Forms
Use these applications to apply for AHCCCS health insurance and KidsCare.
AHCCCS applications will not be used to decide if you can receive cash assistance or food stamps. If you want to apply for these services, you must use an application from the Department of Economic Security (DES). You can download a DES application at:
http://www.azdes.gov/faa/appcenter.asp. You can find a local DES office online at:
http://www.azdes.gov/faa/contact.asp
These forms are saved in PDF format and require you have
Adobe Reader installed on your computer. If you don't have
Adobe Reader you can
get it here for free.
The attached notice explains that your application is going to be placed
on a waiting list for the SSDI-Temporary Medical Coverage program. The
following information gives you more information about the program and
the current application process.
[
Details ]
El aviso adjunto explica que su solicitud va a ser puesta en una
lista de espera para el programa de Cobertura Médica Temporal SSDI. La
información de abajo le da a usted más información sobre el programa y el
proceso de solicitud actual.
[
Detalles
]
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If you are unable to download or print the PDF version of the application, you may
submit a request to have a printed application sent to you.
NOTE: These applications do not apply for individuals who are in need of Arizona Long Term Care Services (ALTCS), such as home health care, nursing facility care, or assisted living. To apply for ALTCS, applicants must contact one of our ALTCS offices.
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