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  • To find a form:
    • Click on the arrows below to sort the list of forms alphabetically by name in ascending or descending order; or
    • Enter the name or number of the form in the “Search Options” field and click on the magnifying glass button.
  • Click on the form name for a description of the form.
  • Click on the PDF button next to the name of the form to open the form.
  • To print or save the form:
    • Put your cursor near the top of the form to display available functions.
    • Click on the print button (or use Control + P) to print the form.
    • Click on the Save button to save a copy of the form.
  • To save the form to your Health-e-Arizona Plus Favorites:
    • Log in to your account; and
    • Click on the star button next to the name of the form.
Forms Hide
     Designation of EBT Alternate Card Holder [ FAA-1004A ]
     Separate Household Status Statement [ FAA-0255A ]
     Cash Programs Personal Responsibility Agreement (PRA) [ FAA-1523A ]
     Illegal Drug Use Statement [ FAA-1415A ]
     Disability Report [ DE-121 ]
     Authorization for the Disclosure of Protected Health Information [ DE-202 ]
     Recent Employment/Training Background [ FAA-0155A ]
     Verification of Living Arrangements/Residential Address [ FAA-0065A ]
     Authorized Representative [ DE-112 ]
     Health Insurance Marketplace Employer Coverage Tool [ OMB 0938-1213 ]
     Report A Change [ FAA-1759A ]
     Request for Quarters of Coverage (QC) History Based on Relationship [ SSA-513 ]
     Application for Benefits [ FAA-0001A ]
     Change Report [ FAA-0412A ]
     Youth in Tribal Foster Care Update [ MA-436 ]
     Nutrition Assistance Drug Testing Agreement [ FAA-1565A ]
     AHCCCS Release of Information Authorization [ DE-200 ]
     Verification of New/Current Employment [ FAA-0053A ]
     Request to Voluntarily Withdraw from an Appeal [ FAA-1693A ]
     Verification of School Attendance [ FAA-0075A ]
     Request for Verification of Unearned Income [ Unearned Income ]
     Request for Verification of Annuity [ DE-235 ]
     Request for Verification of Money Borrowed [ DE-230 ]
     Referral for Potential Benefits [ Potential Benefits ]
     Referral for Social Security Benefits [ SSA Benefits ]
     Referral for Veterans Benefits [ DE-134 ]
     Authority to Release Student Information [ FAA-0060A ]
     ABAWD Participation And Referral Notice [ FAA-1530A ]
     General Delivery Service [ OPS 1-12 ]
     DES Authority to Release Records [ FAA-0059A ]
     Declarations for Medical Assistance, Nutrition Assistance and Cash Assistance [ FAA-1724A ]
     Verification of Terminated Employment [ FAA-1701A ]
     Additional Questions for Children Under Age 19 [ KidsCare ]
     Verification of Other Income [ FAA-1725A ]
     Participant Statement Verification Worksheet [ FAA-1111A ]
     DES Authority to Release Information [ FAA-1765A ]
     Consent for an Assistor [ A-000 ]
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