A Application Forms, Assistance, Cooperation and Voter Registration

Revised 10/24/2023

Policy

To qualify for AHCCCS Medical Assistance (MA), the customer or someone acting responsibly for the customer must submit a signed application. The application must be on a form accepted by AHCCCS.

See MA533 for other requirements for a valid application.

 

1) Application Forms

The Agency accepts the following application forms:

• Health-e-Arizona Plus (HEAplus) Online Application;

• The Department of Economic Security (DES)/Family Assistance Administration (FAA) – Arizona Health Care Cost Containment System (AHCCCS) Joint Application for Benefits;

• Application for Help with Health Coverage Costs;

• Application for AHCCCS Health Insurance and Medicare Savings Programs;

• The Centers for Medicare and Medicaid Services (CMS) Paper Application;

• Breast and Cervical Cancer Treatment Program (BCCTP) Referral Form (BC-100).

 

2) Who May Sign the Application?

Any of the following people may sign the application for a customer:

• The customer;

• The customer’s legal or authorized representative;

• An adult who is in the customer’s MAGI Budget Group or Premium Tax Credit Budget Group (MA602D)

• When the customer is a minor child or is incapacitated, someone acting responsibly for the customer.

The application may be signed in writing, by electronic signature, or by a recorded voice signature.

NOTE     When the person signs with a mark, a third party must witness the signature and sign the application attesting to witnessing the signature.

 

3) Authorized Representatives

The customer may choose a person or an organization as their Authorized Representative. The representative must agree to comply with federal and state conflict of interest and confidentiality requirements.

When an organization is authorized to act on the customer’s behalf, each person that interacts with AHCCCS for that organization must sign an Authorized Representative (DE-112) form. The form may be signed in writing, by electronic signature, or by a recorded voice signature when applicable.

NOTE     When a new authorized representative is from the same organization an updated DE-112 only needs the new representative’s signature. To choose an authorized representative, the customer and representative must provide:

• An Authorized Representative Form (DE-112);

• The Authorized Representative section of the Application for Benefits (FAA-0001A);

• The Authorized Representative section of the Application for AHCCCS Medical Assistance and Medicare Savings Programs (DE-103); or

• A legal document giving the representative the authority to represent the customer. Acceptable documents include:

  • A Financial or General Power of Attorney;

  • Letters of Acceptance of legal guardianship or conservatorship (a petition is not acceptable); or

  • Court orders.

• United HealthCare Authorization of Assistance form

NOTE     An Authorized Representative form is also needed for the person to agree to confidentiality of information provided when:

• a legal document gives the person authority to the represent the customer; or

• a representing organization selects a different person to act on the customer’s behalf.

 

The customer may authorize the representative to do any or all of the following:

• Complete, sign and submit applications, renewal forms, and other documents for the customer;

• Receive copies of the notices and other communications about the customer’s MA; or

• Act on behalf of the customer in all other matters related to MA.

 

The Authorized Representative Form expires when:

• The customer voluntarily withdraws an application;

• The application is denied;

• The application is discontinued, and the customer is no longer receiving MA;

• The customer reapplies after a discontinuance, and the new application date is more than 90 days after the prior application date;

• The customer designates a new Authorized Representative; or

• The customer or Authorized Representative revokes the authorization.

NOTE     The Authorized Representative Form expires 90 days after MA coverage ends.

 

4) Customer Assistance

When needed, Benefits and Eligibility Specialists and other staff will help the customer with the application process. 

Customers may also have someone of their choice help them with the application process. This includes:

• Going with the customer to the local office;

• Helping the customer fill out the application; and

• Representing the customer.

 

5) Customer Cooperation

Customers and their representatives must cooperate in the application process. This includes:

• Providing information and any proof needed;

NOTE     Proof is only requested from the customer when it is not available from previous records and electronic sources, or the proof found conflicts with the customer's statement.

• Reporting changes; and

• Taking any action needed to qualify for the MA program.

 

6) Opportunity to Register to Vote

The National Voter Registration Act (NVRA) of 1993 and Arizona Revised Statutes (ARS) require that public assistance offices provide customers with an opportunity to register to vote at the time of application.

 

Definitions

Term	Definition
Authorized Representative	A person or an organization appointed by the customer to act on their behalf for the application process, renewing eligibility or other communications.
Electronic Signature	An electronic or digital method of identification executed or adopted by a person with the intent to be bound by or to authenticate a record and has the same force and effect as a written signature. The signature must be unique to the person using it and linked to a record in a manner so that if the record is changed the electronic signature is invalidated.
Legal representative	A person authorized by law to represent the customer. This includes: A person appointed by a Court of Law to represent an individual; The natural or adoptive custodial parent of a minor child; or An agency appointed by a Court of Law as guardian of the customer; for example, a tribal social services (foster care) agency.
Organization	An organized body of people with a particular purpose, especially a business, society, or association.

 

Timeframes

Application processing periods vary by program and are initiated by application date. See MA1301.B for program-specific timeframes.

 

Legal Authority

Program	Legal Authorities
All Programs	52 USC 20506 42 CFR 435.907 42 CFR 435.908 42 CFR 435.923 42 CFR 457.340 (KidsCare)