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The customer or the customer’s legal representative may authorize someone else to act on behalf of the customer for the eligibility determination process. However, that person may not be able to authorize release of the customer’s confidential information. In this situation, the customer or legal representative can give permission to release information to AHCCCS by completing and signing any of the forms listed below:
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Form |
Description |
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Release of Information Authorization (DE-200) form |
Allows AHCCCS to ask for a broad range of information in order to determine eligibility. |
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Authorization to Disclose Substance Use Disorder Records to AHCCCS (DE-201) form |
Used to request substance use disorder information from a third party. |
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Authorization to Disclose Protected Health Information to AHCCCS (DE-202) form |
Used to obtain a customer’s medical information. |
It is important to protect confidential information gathered during the eligibility process. See Confidentiality and the Interview for detailed steps.
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Term |
Definition |
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Authorized Representative |
A person, or an organization, authorized by the customer, legal representative, or responsible relative of the customer to act on the customer’s behalf in the AHCCCS eligibility process. |
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Legal Representative |
A legal representative is:
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Programs |
Legal Authority |
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All Programs |
42 CFR 431.300 through 307 45 CFR, Part 160 and Part 164 (subparts A and E) AAC R9-22-512 |