AHCCCS | Mountain Park Health

AHCCCS Eligibility Pre‑Screening Form (HEAplus‑aligned)

Use this form to gather information needed to apply for AHCCCS Medical Assistance via Health‑e‑Arizona Plus (HEAplus). This pre‑screen does not replace the official online application.

Applicant / Patient Information

Applicant Full Legal Name

First

Other Names Used (Aliases, Maiden)

Date of Birth

MM slash DD slash YYYY

Phone Number

Physical Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Mailing Address (if different)

Street Address

Arizona Residency Status

I intend to live in Arizona (even if I do not have a fixed address).

I recently moved to Arizona and I am looking for work or accepted a job offer.

List ALL people who live in your household (include spouses/partners, children, and anyone you claim on your tax return). For each person, provide: full name, DOB, relationship, whether applying for medical coverage, and lives with you?

Household Members

Full Name

Date of Birth

Relationship

Applying for Medical Coverage?

Lives with Applicant?

Ethnicity (optional)

Please write how you identify. Examples include: Hispanic or Latino, Not Hispanic or Latino. You may leave blank.

Ethnicity (free text)

Race (optional – you may include multiple)

Please write how you identify. Examples include: American Indian or Alaska Native, Asian, Black or African American, Middle Eastern or North African (MENA), Native Hawaiian or Other Pacific Islander, White, or other. You may leave blank.

Race (free text – list all that apply)

Citizenship / Immigration (for each applicant)

Purpose of Information Release

U.S. Citizen

U.S. National

Lawful Permanent Resident (Green Card) – provide A‑Number

Other qualified non‑citizen status – provide document type/number

Not providing status – I am applying for emergency services only

A‑Number / USCIS document ID (if applicable)

Pregnancy (if applicable)

Currently Pregnant

Yes

Expected Due Date

Number of Unborn Children (for household size)

Disability, Medicare & ALTCS Screening

Disability, Medicare & ALTCS screening

Blind or disabled, or applying based on disability

Currently receiving SSI (Supplemental Security Income)

Receiving Social Security Disability Insurance (SSDI)

Receiving Medicare (Parts A/B)

Interested in Arizona Long Term Care System (ALTCS) services

Income (MAGI) – current month and expected annual

Tax filing status for current year (e.g., single, married filing jointly, head of household)

List tax dependents you expect to claim this year

Check ALL income types received by any household member (report gross, before taxes):

Wages / salary (attach last 4 pay stubs if available)

Self‑employment or gig income

Unemployment compensation

Social Security (retirement or disability) – do NOT include SSI

Pension or retirement distributions

Interest / dividends / capital gains

Rental / royalty income

Alimony received (for divorces finalized before 1/1/2019)

Other taxable income

Income NOT counted for MAGI (no need to list): SSI, child support received, veterans’ disability benefits, workers’ compensation, TANF, most scholarships/grants. Provide if asked for other programs.

Total gross household income this month ($)

Expected annual household income for coverage year ($)

Deductions (if applicable)

Deductions

Alimony paid (pre‑2019 orders)

Student loan interest

IRA / HSA contributions

Self‑employment expenses (attach ledger)

Current Coverage & Special Circumstances

Current Coverage

Currently enrolled in health insurance (employer, marketplace, Medicare)

Lost coverage in the last 60 days (provide date)

Currently incarcerated

American Indian/Alaska Native or eligible for services from IHS/tribal/urban Indian clinic

Veteran or active-duty military household member

Student status (full‑time) for any household member under 22

Foster care (under 26 and formerly in foster care)

Authorized Representative & Communication Preferences

Authorized representative name & contact (if any)

Application Status Consent

I consent to texts/emails about my application status

Preferred language for notices

Document Checklist (provide if requested)

Document Checklist

Photo ID (driver’s license or state ID)

Proof of Arizona residency (lease, utility bill, employer statement)

SSN card or SSA proof of application

Citizenship/immigration documents (if applicable)

Proof of income (pay stubs, award letters, tax forms)

Pregnancy verification (doctor statement)

Medicare card (if applicable)

Consent Acknowledgement

Consent(Required)

I confirm that the information I provided is true and accurate to the best of my knowledge. I understand this is a pre-screening form and that I will be contacted to complete the official application and required authorizations.