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Individual and Family



How We Will Use Your Information
ALTCS
  The following information describes how your personal information will be used by Health-e-Arizona Plus, AHCCCS, DES, and their contractors.
  • We need to collect personal information about you and people in your household in order to determine program eligibility.
  • We will use the personal information to get information from applicable sources (for example: electronic sources, employers, government agencies and medical providers). This includes protected health information when needed to determine eligibility.
  • We use your information, including Social Security number, to computer match with state, local, and federal agencies and our other programs to verify information. Income and verification systems such as the Social Security Administration, the Internal Revenue Service, State Unemployment Insurance and State Wage may be used. This information may affect eligibility and benefit level.
  • This information will be available to Health-e-Arizona Plus, AHCCCS, DES, and their contractors. Personal information will only be used for the purposes for which it was provided and will not be shared with anyone except as required by law. This information will be used to monitor compliance with program regulations and for program management.
  • Applying and providing information is voluntary, but some information is required to make a determination. For example, you must provide or apply for a Social Security number for every applicant. (Immigrants who are not legally able to obtain a Social Security number are not required to provide one.) Therefore, if personal information is not provided, you may not be eligible for benefits.
 
  • We need to investigate and contact any sources necessary to confirm the accuracy of the information needed for your eligibility.
 
  • Health-e-Arizona Plus, AHCCCS, DES, and their contractors have taken several steps to safeguard your information. This includes, but is not limited to, authentication, monitoring, auditing, and encryption. Security measures have been put into the design and use of the entire environment as part of our commitment to risk management. This includes security scans and a highly secured hosting environment.
  • Your information will be kept for at least seven years. We are required by law to collect and securely store this information.
  • Domestic Violence Considerations - Some program requirements may be difficult or dangerous for victims or survivors of domestic violence, sexual harassment, sexual assault, or stalking, and their families. Speak with your eligibility specialist, to determine whether you may be exempt from these requirements. We will keep all information you provide private, as required by law. Immediate free, confidential help is available through any of the following:
  • Arizona Sexual and Domestic Violence Services Helpline - Monday-Friday 8:30 a.m. to 5:00 p.m., and until 7:00 p.m. on Tuesdays. You may call them at (602) 279-2980, 1-800-728-6400, or text (520) 720-3383.
  • National Domestic Violence Hotline - Available 24 hours - 1-800-799-SAFE (7233) or TTY 1-800-787-3224.
  • National Sexual Assault Hotline - Available 24 hours - 1-800-656-HOPE (4673).
  The laws that support the information above include, but are not limited to:
  • Social Security Act (SSA) of 1935 (Section 1137) as amended by P.L. 98-369 for Social Security number requirements.
  • Social Security Act (SSA) Section 402(a)(7); 42 U.S.C. 602(a)(7)(C); and Consolidated Appropriations Act, 2022, section 703 for domestic violence considerations.
  • 45 CFR Part 160; 45 CFR 164 Subparts A and E; and 7 CFR 273.2(b)(4) for privacy information.
  • ARS §41-1959 and AAC R6-12-102 for confidential information and permissible disclosure.
  • ARS §41-1346 for state and local public records management.
  • AAC R9-22-1412 and AAC R6-12-205 for collection of information.
  The laws listed above can be found at the following web sites and at a public library:
  • Code of Federal Regulations (CFR): www.ecfr.gov
  • Arizona Revised Statutes: http://www.azleg.gov/arstitle
  • Arizona Administrative Code (AAC): https://azsos.gov/rules/arizona-administrative-code
  • Social Security Act (SSA): www.ssa.gov/OP_Home/ssact/ssact.htm
 
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How We Will Use Your Information
About this page
This page explains how we will use your information. You can read this information at any time by clicking on MessageCenter in the tool bar.

For more details, go to the Eligibility Policy Manual.

How to complete this page
To continue, you must read the information and check the box that you agree.
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How We Will Use Your InformationAbout this page
This page explains how we will use your information. You can read this information at any time by clicking on MessageCenter in the tool bar.

For more details, go to the Eligibility Policy Manual.

How to complete this page
To continue, you must read the information and check the box that you agree.
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  • {0} is NOT eligible for HPE – Received HPE in last 24 months
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  • {0} is NOT eligible for HPE – Age 65 or older and no minor children
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  • {0} is NOT eligible for HPE – Receiving Medicare and no minor children
    •  Presumptive Eligibility Alert!

    Warning!

       

    If you switch to the Hospital Presumptive Eligibility (HPE) at this point, you will NOT be able to use this application to submit as a full AHCCCS application. You will need to ensure that a full AHCCCS application is submitted later, if the HPE application is approved.


    Select ‘Return to Full Application’ to continue the full AHCCCS application. You will have an opportunity to also submit a HPE application at the end of the full application process.


    Select ‘Continue with HPE’ to apply ONLY for Hospital Presumptive Eligibility.
       
    Return To Full Application Continue to HPE

    Stop
       

    This application includes Nutrition Assistance and/or Cash Assistance. You will not be able to help your customer apply for these programs on this application if you choose to go to the Hospital Presumptive Eligibility (HPE) application.


    Select ‘Return to Full Application” to continue applying for all programs.


    Select ‘Continue with HPE’ to apply for ONLY Hospital Presumptive Eligibility. You will need to create another application if your customer wants to apply for Nutrition Assistance or Cash Assistance.
       
    Return To Full Application Continue to HPE

    Warning:Some persons cannot qualify for Hospital Presumptive Eligibility

       

    Warning:No one in this application can qualify for Hospital Presumptive Eligibility

       

    HPE is only available to persons who have not had HPE in the past 24 months.

    Hospital Presumptive Eligibility (HPE) is not available to persons who are age 65 or older when there are no minor children in the household.

    Hospital Presumptive Eligibility (HPE) is not available to persons who are receiving Medicare unless there are minor children in the household.

       

    To continue this application for all persons in this application, click on the “Return to Full Application” button.


    To continue applying for HPE for the other persons in this application, click on the “Continue HPE for Other Persons” button.

    Click “OK” to return to the full application.
       
    Return To Full Application Continue HPE for other persons
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