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Care System (ALTCS) To start the application process, (Arizona Health Care Cost Containment System)

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DE-101_DE-202 Combo form (02/2022) Page 1 of 7
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). You may also
complete this form and return it using one of the methods found on page 4 of this Request for
Application.
Customer Information
Customer’s Name (Last, First, Middle)
Customer’s Date of Birth
Customer’s Social Security Number
Male Female
Marital Status
Never Married
Divorced
Married (including separated if not legally divorced)
Widowed Date of s
pouse’s death:
Spouse’s Name (Last, First, Middle)
Spouse’s Date of Birth
Spouse’s Social Security Number (optional if not applying)
Customer’s Home Address
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
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
DE-101_DE-202 Combo form (02/2022) Page 2 of 7
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
Seizure Disorder
If the customer is under 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
DE-101_DE-202 Combo form (02/2022) Page 3 of 7
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 applicant.
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 box below; and
• sign this form below.
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 below; 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.
DE-101_DE-202 Combo form (02/2022) Page 4 of 7
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:
• Fax (toll-free): 888-507-3313
• Email: altcsregistration@azahcccs.gov
• Mail: ALTCS
801 East Jefferson Street
MD 3900
Phoenix, AZ 85034
A completed Request for Application may also be taken to a local ALTCS office:
CASA GRANDE
201 East Cottonwood Lane, Suite 2
Casa Grande, Arizona 85122
PHOENIX
801 East Jefferson Street
Phoenix, Arizona 85034
CHINLE
Tseyi Shopping Center, Hwy 191
Chinle, Arizona, 86503
PRESCOTT
3262 Bob Drive, Suite 11
Prescott Valley, Arizona 86314
COTTONWOOD
1500 East Cherry Street, Suite I
Cottonwood, Arizona 86326
TUCSON
7202 E Rosewood Street, Suite 125
Tucson, Arizona 85710
FLAGSTAFF
2717 North Fourth Street, Suite 130
Flagstaff, Arizona 86004
YUMA
1800 E Palo Verde St
Yuma, Arizona 85365
KINGMAN
2400 Airway Avenue
Kingman, Arizona 86409
DE-101_DE-202 Combo form (02/2022) Page 5 of 7
Authorization To Disclose Protected Health
Information To AHCCCS
Attention ALTCS Customer:
Please complete the “Authorization to Disclose Protected Health Information to AHCCCS”
form. A signature on the form is required by one of the following people:
• Customer;
• Customer’s parent if the customer is under the age of 18; or
• Customer’s Legal Guardian or Legal Representative. Copy of court documents must be
provided.
Return this completed form using one of the return options below. For any questions, call (602)
417-6600 or toll-free (888) 621-6880. Please note, returning this form quickly will allow us to
assist in getting medical documentation for your application.
Return Options:
Fax (toll-free): 888-507-3313
Email: altcsregistration@azahcccs.gov
Mail: AHCCCS
801 E. Jefferson St.
MD 3900
Phoenix, AZ 85034
DE-101_DE-202 Combo form (02/2022) Page 6 of 7
Return Information to:
AHCCCS
801 E. Jefferson St. MD 3900
Phoenix, AZ 85034
Fax: 888-507-3313
AHCCCS Worker Name:
Email:
Phone Number:
Customer Name: Date of Birth:
AHCCCS ID Number or PID: Date of Request:
Customer Address:
Social Security Number (SSN):
(SSN is optional but may help
the provider locate records)
For use by AHCCCS customers/applicants who want a doctor or other
entity to give AHCCCS their protected health information.
I give my permission for any health care provider to disclose any of my protected health
information to AHCCCS, for the purpose of determining my eligibility for any of the publicly-
funded programs administered by AHCCCS. I give AHCCCS permission to share this
information with the Arizona Department of Economic Security, Disability Determination
Services Administration, if necessary, to determine my disability status.
In addition, by checking these boxes, I specifically authorize the disclosure of the following
types of medical records:
HIV/AIDS and communicable disease related information and/or records
Mental health information and/or records
Genetic testing information and/or records
If the information to be disclosed comes from a school, please fill out this box:
I specifically authorize the holder of my information to disclose all of my educational and
evaluation records in its possession to AHCCCS.
By signing this Authorization, I understand that:
• AHCCCS is required by state and federal law to keep confidential the information
described above and may only use or disclose that information with my approval, for
purposes directly related to the administration of the AHCCCS program, or as otherwise
permitted or required by law.
Authorization To Disclose Protected Health Information
To AHCCCS
DE-101_DE-202 Combo form (02/2022) Page 7 of 7
• I also understand that if I refuse to sign or revoke this authorization, AHCCCS may not
be able to determine my current or future eligibility for the publicly funded medical
assistance programs administered by AHCCCS. As a result, my application for
assistance may be denied or the assistance may be discontinued.
• I may revoke this authorization, in writing, at any time, by completing an AHCCCS
“Revocation of Authorization” form, and sending it to:
Arizona Health Care Cost Containment System
Office of Legal Assistance
Attention: Privacy Officer
801 E. Jefferson, MD 6200
Phoenix, AZ 85034
Phone 602-417-4232
Fax 1-602-253-9115
Once AHCCCS receives the revocation, this authorization will be revoked, except to the extent
that AHCCCS has already taken action in reliance upon this authorization.
Please choose one of the following:
This authorization will expire on:
Insert specific date:
Insert specific event:
The customer's signature is required to get medical records. If the customer is under
the age of 18, the signature of the customer's parent is needed. If the customer has a
legal guardian or legal representative, the signature of the legal guardian or legal
representative is needed.
Signature:
Date:
Printed name of person signing form:
Relationship to Customer:
Printed name of witness (only needed if
customer signed with mark):
Signature of witness:
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Completed 23 May 2022

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