Get Az De-103 2012

Filling out the AZ DE-103 form online is a crucial step in applying for Arizona’s Medical Assistance Program. This guide will help users navigate the form, ensuring all necessary information is accurately provided.

Follow the steps to successfully complete the AZ DE-103 online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor. This action allows you to access the necessary information needed to complete your application.
2. Begin by providing your personal information in the designated fields. This includes your first and last name, date of birth, and Social Security number. If applicable, include information about your spouse or dependent children living with you.
3. Next, indicate whether you are applying for AHCCCS Health Insurance or for help with Medicare costs by checking the corresponding 'Yes' or 'No' boxes. Be sure to answer all questions on pages 1 through 3 relevant to each applicant.
4. Complete the income section, detailing all sources of income you and your family receive. This may include employment income, Social Security benefits, or any other applicable income types. Attach verification documents if necessary.
5. If applicable, fill out the section regarding veteran status and potential benefits. Provide information about any medical coverage you or your spouse may currently have apart from Medicare.
6. Review the rights and responsibilities outlined in the application. It is essential to understand your rights while applying for AHCCCS and the obligations that come with it.
7. Sign and date the application. If you have a legal guardian or representative, include their information and signature where required.
8. Keep pages A, B, C, and D for your records. Mail the completed application pages 1 through 3 to the address specified in your instructions or return them via the provided channels.
9. Finally, you can save your changes, download the completed form, and share it as needed. Make sure to follow any additional instructions for submission or follow-up.

Start filling out the AZ DE-103 online today to apply for the health assistance you may qualify for.