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Behavioral Health Services BlogBehavioral Health Services Blog

Division of Behavioral
Health Services
150 N. 18th Avenue, 2nd Floor
Phoenix, AZ 85007
(602) 364-4558
(602) 364-4570 Fax
Toll-free:1-800-867-5808
dbhsinfo@azdhs.gov

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Division of Behavioral Health Services

AHCCCS Eligibility Manual: Blank Forms


Form Name Form Number Agency*
Health-e Arizona Online ApplicationPDF N/A N/A
Required Forms for all applications    
AHCCCS Application Checklist/CoversheetPDF ADHS AE-02 ADHS
AHCCCS Health Insurance Application: EnglishPDF SpanishPDF   AHCCCS
Authorization for Release of Information: EnglishPDF SpanishPDF ADHS AE-03 ADHS
Next Steps EnglishPDF SpanishPDF ADHS AE-04 ADHS
ADES/FAA Language NeedsPDF FA-001-L ADES/FAA
Supplemental Forms    
Authorization for the Disclosure of Protected Health Information
EnglishPDF SpanishPDF		 DE-202 AHCCCS
PM Form 3.10.1 SMI DETERMINATIONPDF 3.10.1 ADHS
AHCCCS Application Referral Turn Around DocumentPDF
For applications sent to DES 		ADHS AE-06 ADHS
Authorization for AHCCCS to Request Information from SSAPDF
For applications sent to AHCCCS SSI-MAO Unit		 AH-502 AHCCCS
AHCCCS Medical Benefit Disability ReportPDF
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 AHCCCSPDF DE-121 AHCCCS
Request for Verification of EmploymentPDF DE-206 AHCCCS
Record of Collateral Verification of EmploymentPDF UE-309 AHCCCS
AHCCCS Medical Benefits - Referral for Potential BenefitsPDF DE-135 AHCCCS
AHCCCS Medical Benefits - Referral for Veterans BenefitsPDF DE-134 AHCCCS
Application Status Request (Fax)PDF ADHS AE-07 AHCCCS
Decline to Participate in the Screening and/or Referral Process for AHCCCS Health Insurance: EnglishPDF SpanishPDF ADHS AE-08 AHCCCS
Request for Vital Records InformationPDF DE-242 AHCCCS
AHCCCS Report of Continuing DisabilityPDF DE-123 AHCCCS
AHCCCS Health Insurance Breast and Cervical Cancer Treatment Program ReferralPDF BC-100 AHCCCS
Request for Information for Persons Referred by Tribal/Regional Behavioral Health AuthorityPDF MA-433 AHCCCS
Notice to Tribal/RBHA Designee on Referral ApplicationPDF MA-434 AHCCCS
Renewal Verification from the Tribal/Regional Behavioral Health AuthorityPDF MA-435 AHCCCS
AHCCCS Health Insurance Notice of ActionPDF MA-532 AHCCCS

* Indicates the state agency that has developed the form.