Articles

Re: Arizona Health Care Cost Containment System (AHCCS)

Verification Checklist - For Application

• Proof of Social Security Numbers and Citizenship or Lawful Alien Status

• Your and your spouse's Social Security Card or letter from Social Security showing your Social Security numbers.

• Your and your spouse's birth certificate, passport, baptismal certificate or Certificate of Naturalization, if a citizen of the United States.

• Alien Registration Receipt Card for you and your spouse, if a lawful alien resident.

• Drivers license for you and your spouse

• Proof of Resources or Assets (things you and your spouse own)

• Copies of last three account statements for all bank accounts, (checking accounts, savings accounts), brokerage accounts, Money Market accounts and copies of all Certificates of Deposit (CDs)

• All Life or burial insurance policies or contracts and premium statement

• Any Trust which names either of you as a grantor or a beneficiary of the trust.

• Any promissory note you and your spouse own.

• Current Will, Living Will, Trust, Power of Attorney, Pre-Marital Agreement

• Statements showing the value of all Mutual Funds, Stocks certificates, Bonds, IRAs, deferred annuity accounts or policies or U.S. Savings Bonds or any other asset.

• Original mortgage papers unless satisfied.(mortgage note, amortization schedule), Titles, registration, to any vehicles or deeds to real property (your home or other land) mobile home title that you may own.

• Insurance premium statements for vehicles, homes and jewelry

• Proof of your Income and your Spouse's Income (money that you receive)

• Current award letters or check stubs for any pension benefits you receive.

• The annuity contract if you receive annuity payments.

• Pay-stubs if you or your spouse is employed.

• Your income tax return if you or your spouse is self-employed.

• Provide the following items only if applying for Long Term Care:

• Medicare and Supplemental Health Insurance Policy, Card and premium statement. (Contact the companies and request written policy information on all policies stating current face and cash surrender value.

• Bills or receipts for Health Insurance premiums may be allowed as a deduction).

• Long term care insurance policy, and written proof of monthly premium paid.

• Health Care Surrogate

• The names, addresses and phone numbers for any doctors from whom you are receiving services and any hospitals to which you have been admitted. Any medical records you have will also be helpful.

• Your marriage certificate or other proof of marriage.

• Proof of your rent or mortgage, property taxes, homeowner's insurance and utilities (these items may be allowed as a deduction).

• MISCELLANEOUS ITEMS FOR YOU AND YOUR SPOUSE

• Copy of funeral, burial, and cremation contracts, cemetery lots, plots

• All rental agreements and maintenance/condominium fee agreements

• Documentation (bank statements or cancelled checks) showing gifts made within the last three years. Must have exact date of gift and amount.

• "Sale" information of all assets within the last three years including amount of proceeds from sale, and where funds went

• Closing documentation for all certificates of deposits, insurance policies, stock certificates, annuities closed within the last three years

• Last three statements from all assets closed within last three years and documentation showing where the funds went

• All written documentation stating the gross current amount of all pensions and deductions. If no documentation, call the company to send the written documentation to the home address

• Documentation stating the gross current monthly social security benefits and medicare deduction for both. OR, call Social Security Administration at 1-800-772-1213 and use the automated service prompts to request proof of current monthly payment to be mailed to the address on record. When prompted, press 1, press 3, and then press 2. You will then be asked to give the social security number on which benefits are paid (as shown on the medicare card) and the name of the person.