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Division of Behavioral Health Services

AHCCCS Eligibility Manual: Blank Forms

Form Name Form Number Agency*
Health-e Arizona Online Application N/A N/A
Required Forms for all applications    
AHCCCS Application Checklist/Coversheet ADHS AE-02 ADHS
AHCCCS Health Insurance Application: English Spanish   AHCCCS
Authorization for Release of Information: English Spanish ADHS AE-03 ADHS
Next Steps English Spanish ADHS AE-04 ADHS
ADES/FAA Language Needs FA-001-L ADES/FAA
Supplemental Forms    
Authorization for the Disclosure of Protected Health Information
English Spanish
AHCCCS Application Referral Turn Around Document
For applications sent to DES
Authorization for AHCCCS to Request Information from SSA
For applications sent to AHCCCS SSI-MAO Unit
AHCCCS Medical Benefit Disability Report
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
Informe de Discapacidad de AHCCCS DE-121 AHCCCS
Request for Verification of Employment DE-206 AHCCCS
Record of Collateral Verification of Employment UE-309 AHCCCS
AHCCCS Medical Benefits - Referral for Potential Benefits DE-135 AHCCCS
AHCCCS Medical Benefits - Referral for Veterans Benefits DE-134 AHCCCS
Application Status Request (Fax) ADHS AE-07 AHCCCS
Decline to Participate in the Screening and/or Referral Process for AHCCCS Health Insurance: English Spanish ADHS AE-08 AHCCCS
Request for Vital Records Information DE-242 AHCCCS
AHCCCS Report of Continuing Disability DE-123 AHCCCS
AHCCCS Health Insurance Breast and Cervical Cancer Treatment Program Referral BC-100 AHCCCS
Request for Information for Persons Referred by Tribal/Regional Behavioral Health Authority MA-433 AHCCCS
Notice to Tribal/RBHA Designee on Referral Application MA-434 AHCCCS
Renewal Verification from the Tribal/Regional Behavioral Health Authority MA-435 AHCCCS
AHCCCS Health Insurance Notice of Action MA-532 AHCCCS

* Indicates the state agency that has developed the form.

Note: Information provided in PDF files, unless otherwise indicated.