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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
DE-202 AHCCCS
PM Form 3.10.1 SMI DETERMINATION 3.10.1 ADHS
AHCCCS Application Referral Turn Around Document
For applications sent to DES
ADHS AE-06 ADHS
Authorization for AHCCCS to Request Information from SSA
For applications sent to AHCCCS SSI-MAO Unit
AH-502 AHCCCS
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
DE-121 AHCCCS
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.