Request For Application For Arizona Long Term Care System (ALTCS)		

Customer Address:
     
     
     
     	

To start the application process, you can call us at 888-621-6880 (toll-free) or register an application online at Health-e-Arizona Plus. You may also complete this form and return it using one of the methods found on page 4 of this Request for Application. Missing or incomplete information may cause a delay in the processing of your application. Bolded questions are required to be answered in order for us to register the application.

Customer Information
Customer’s Legal Name (First, Middle Initial, Last, Suffix):
     	Customer’s Date of Birth:
     	
Customer’s Social Security Number:
     	 Male	 Female	
Marital Status:
	 Never Married	 Married (including separated if not legally divorced) 
 Divorced	 Widowed	Date of spouse’s death:      	
Spouse’s Legal Name (First, Middle Initial, Last, Suffix):
     	Spouse’s Date of Birth:
     	
Spouse’s Social Security Number (optional if not applying):
     	
Customer’s Home Address: 
     
     
     
     	Customer’s Mailing Address (if different from home address):
     
     
     
     	
Phone Number:
     	E-mail Address:
     	

Authorized Representative/Spouse and Legal Guardian/Conservator Information
Name of the Customer’s Authorized Representative: 
     	Relationship to Customer:
     	
Representative Date of Birth (optional):      	Name of the Representative Organization (when applicable):      
	
Name of the Customer’s Legal Guardian/Conservator:
     	Relationship to Customer:
     	
Authorized Representative’s Mailing Address:
     	
City:
     	State:
     	ZIP Code:
     	
Phone Number:
     	E-mail Address:
     	
Legal Guardian’s/Conservator’s Mailing Address:
     	
City:
     		State:
     	ZIP Code:
     	
Phone Number:
     	E-mail Address:
     	

Customer’s Current Living Arrangement
Where is the customer currently residing?  Hospital		 Nursing Facility
 At Home		 Other:      	Date Admitted:
     	Expected Date of Discharge:
     	
Name of the Hospital, Assisted Living or Nursing Facility:	
     			Phone Number:
     	
Hospital, Assisted Living, or Nursing Facility Address:
     	
City:      	State:      	ZIP Code:      	

Accommodations for Printed Letters
Does the customer, authorized representative, or legal guardian have a visual impairment that requires an alternative format for printed letters? 
 No		 Yes If yes, who needs the accommodation?       
If yes, what kind of alternative format do you need? Please choose one option:
 Readable PDF sent by secure email
 Large print: larger print letters sent by U.S. mail will be provided Arial 24-point font.
 Other:      	

Additional Questions
Does the customer need help paying for medical expenses from the last three months? 
Is the customer pregnant or had a pregnancy end in the last 5 months?	 Yes	 No If yes, what months? 
     ,     ,     
 Yes	 No	
Is the customer receiving services from the DES Division of Developmental Disabilities? 	 Yes	 No
If yes, date services began:      	
Prior to the age of 18 was the customer diagnosed with any of the following medical conditions? Check all that apply. 	 Autism
 Cerebral Palsy
 Intellectual/Cognitive Disability
 Down syndrome 
 Seizure Disorder	
If the customer is under the age of 6, has the customer been diagnosed with Developmental Delay?  	 Yes	 No	
Is the customer a trustor, trustee, or beneficiary of any type of trust?	 Yes	 No	
Has the customer sold, traded, transferred, or given away any assets within the last five years? 	 Yes	 No	
Interview Information: An interview is required to complete the ALTCS application process. The customer is not required to attend the financial interview if the legal guardian/conservator or authorized representative completes the interview for the customer.
What are the best days and times for you to complete the interview? 	
 Monday 	Time:      	
 Tuesday	Time:      	
 Wednesday	Time:      	
 Thursday	Time:      	
 Friday	Time:      	
Does the person completing the interview need an interpreter?  Yes		 No	If yes, what language?      	

How We Will Use Your Information
The following information describes how your personal information will be used by Health-e-Arizona Plus, AHCCCS, DES, and their contractors.
•	We will use your information, including Social Security number, to computer match with financial institutions, state, local, and federal agencies, and our other programs to verify information. Income and verification systems such as the Social Security Administration, State Unemployment Insurance, and State Wage may be used. This information may affect eligibility and benefit level.
•	Applying and providing information is voluntary, but some information is required to make a determination. For example, you must provide or apply for a Social Security number for every applicant. (Immigrants who are not legally able to obtain a Social Security number are not required to provide one.) Therefore, if personal information is not provided, you may not be eligible for benefits.

Name of Person Completing Form:
     	Phone Number:
     	

The person completing this form is the:
 Customer
 Spouse of the customer
 Parent of the customer (if the customer is a minor)
If one of the boxes above is checked, the person completing this form must:
•	check the on the next page; and 
•	sign this form on the next page.
If one of the boxes above is NOT checked, the person completing this form may: 
•	complete an Authorized Representative form found at: https://www.azahcccs.gov/Members/GetCovered/apply.html;
•	attach the completed Authorized Representative form with this request for an application;
•	check the box on the next page; and
•	sign this form on the next page. 

A request for an application may be returned without the completed authorized representative form, checking the box below and signing below, but may cause the application process to take more time.
 I agree to allow you to check information sources and use it for this application.
Signature
     	
Date
     	

AHCCCS complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.

To submit a Request for Application by phone, or for help contact:
Arizona Long Term Care System (ALTCS) 
Call (toll-free): 888-621-6880

A completed Request for Application may also be returned by: 
•	Online: Health-e-Arizona Plus
•	Fax (toll-free): 888-507-3313
•	E-mail: altcsregistration@azahcccs.gov 
•	Mail:	ALTCS
		150 N. 18th Ave 
	MD 3900
	Phoenix AZ 85007

A completed Request for Application may also be taken to a local ALTCS office:

CHINLE
Tseyi Shopping Center Hwy 191
Chinle AZ 86503
	PHOENIX
150 N. 18th Ave
Phoenix AZ 85007
	
FLAGSTAFF
2717 N Fourth St Ste 130
Flagstaff AZ 86004
	TUCSON
7202 E Rosewood St Ste 125
Tucson AZ 85710
	
KINGMAN
2400 Airway Ave
Kingman AZ 86409
	YUMA
1800 E Palo Verde St
Yuma AZ 85365