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AHCCCS Eligibility Manual Home Page
   
AHCCCS Eligibility Manual
Blank Forms
 
*Some of the files on this page are in PDF format.  In order to view, Acrobat Reader™ is required. 
 
Screening Forms Form Number Agency*
AHCCCS Eligibility Screening, ADHS AE-01 [PDF 22K] ADHS AE-01 ADHS
 
Required Forms for all applications    
AHCCCS Application Checklist/Coversheet [PDF 29K] ADHS AE-02 ADHS
AHCCCS Health Insurance Application:
English  [PDF 318K]                                                      Spanish [PDF 351K]		   AHCCCS
Authorization for Release of Information:
English  [PDF 7K]
Spanish [PDF 7K]		 ADHS AE-03 ADHS
Next Steps:
English [PDF 70K]
Spanish [PDF 71K]		 ADHS AE-04 ADHS
ADES/FAA Language Needs [PDF 131K] FA-001-L ADES/FAA
     
Supplemental Forms    
AHCCCS Application Referral Turn Around Document [PDF 16K] - for applications sent to DES ADHS AE-06 ADHS
Authorization for AHCCCS to Request Information from SSA [PDF 24K] - for applications sent to AHCCCS SSI-MAO Unit AH-502 AHCCCS
AHCCCS Medical Benefit Disability Report [PDF 142K] - for applications sent to AHCCCS SSI-MAO Unit for persons who do not meet functions criteria: a) Inability to live independently; or b) risk of serious harm to self or others DE-121 AHCCCS
Informe de Discapacidad de AHCCCS [PDF 144K] DE-121 AHCCCS
Request for Verification of Employment [PDF 45K] DE-206 AHCCCS
Record of Collateral Verification of Employment [PDF 37K] UE-309 AHCCCS
AHCCCS Medical Benefits - Referral for Potential Benefits [PDF 26K] DE-135 AHCCCS
AHCCCS Medical Benefits - Referral for Veterans Benefits  [PDF 45K] DE-134 AHCCCS
Application Status Request (Fax) [PDF 39K] ADHS AE-07 AHCCCS
Decline to Participate in the Screening and/or Referral Process for AHCCCS Health Insurance:
English  [PDF 20K]
Spanish [PDF 11K]		 ADHS AE-08 AHCCCS
Request for Vital Records Information [PDF 27K] DE-242 AHCCCS
AHCCCS Report of Continuing Disability [PDF 70K] DE-123 AHCCCS
AHCCCS Health Insurance Breast and Cervical Cancer Treatment Program Referral [PDF 42K] BC-100 AHCCCS
Request for Information for Persons Referred by Tribal/Regional Behavioral Health Authority [PDF 87K] MA-433 AHCCCS
Notice to Tribal/RBHA Designee on Referral Application [PDF 83K] MA-434 AHCCCS
Renewal Verification from the Tribal/Regional Behavioral Health Authority [PDF 27K] MA-435 AHCCCS
AHCCCS Health Insurance Notice of Action [PDF 43K] MA-532 AHCCCS

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