The Care 1St Arizona Prior Authorization form is a crucial document designed to facilitate healthcare coverage for individuals with disabilities who are aged between 16 and 64. This form collects essential information about the applicant's personal details, income, assets, and medical history to determine eligibility for Medicaid benefits. Completing the form accurately and submitting it promptly is vital to ensure that applicants receive the necessary support without unnecessary delays.
When filling out the Care 1St Arizona Prior Authorization form, follow these guidelines:
Avoid these common mistakes:
Filling out the Care 1St Arizona Prior Authorization form is an important step in securing healthcare coverage. Here are key takeaways to keep in mind:
Following these guidelines will help streamline the process and improve your chances of a successful application.
The Care 1St Arizona Prior Authorization form is designed for individuals seeking healthcare coverage through Medicaid. It specifically targets persons with disabilities who are between the ages of 16 and 65 and are working. The form collects essential information to determine eligibility for Medicaid benefits.
To complete the form, provide accurate information in all required fields. You will need to include personal details such as your name, address, and contact information. Additionally, you must disclose income sources, assets, and any existing health insurance coverage. If you require more space for any section, feel free to attach a separate sheet. Make sure to write "none" if an answer is not applicable.
If you need assistance, you can contact your local Medicaid office. Alternatively, you can call the Care 1St toll-free number at 1-888-544-7996 for support. If language is a barrier, interpreter services are available at no cost. For individuals who are deaf or have hearing problems, a TTY line is accessible at 1-800-220-5404.
You must report all sources of income, including wages, Social Security, unemployment benefits, and any money received from friends or relatives. Provide the total or gross income before any deductions. If you are self-employed, submit copies of your most recent federal tax forms. You will also need to attach proof of earnings, such as paycheck stubs, for the last month.
Yes, you must disclose any assets or resources you or your spouse have. This includes checking and savings accounts, retirement accounts, vehicles, and property other than your home. You will need to provide proof of ownership and value for these assets.
If you have Medicare or another form of health insurance, you must indicate this on the form. Additionally, you will need to provide details such as the insurance company's name, policy number, and monthly premium costs. Proof of coverage and payment should also be submitted with your application.
Providing false information can have serious consequences. If it is discovered that you knowingly submitted incorrect information or withheld relevant details, you may face legal penalties for fraud. Furthermore, you could be required to repay any Medicaid benefits received inappropriately.
To check the status of your application, contact your local Medicaid office or the Care 1St customer service line. They can provide updates on your application status and any additional steps you may need to take.
By applying for Medicaid, you agree to provide truthful information and assist in verifying your eligibility. You must report any changes in your circumstances, such as moving out of state or changes in income, within 10 days. You also have the right to request a Fair Hearing if you believe the decision regarding your application is unfair or incorrect.
The Care 1St Arizona Prior Authorization form is essential for individuals seeking healthcare coverage through Medicaid. However, several other forms and documents often accompany this application to ensure a smooth process. Below is a list of related documents that may be required.
Each of these documents plays a crucial role in the Medicaid application process. Ensure all required forms are completed accurately to facilitate timely processing of the Care 1St Arizona Prior Authorization form.
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BHSF Form 1-MPP
Rev. 04/05
Prior Issue Obsolete
II
For Agency Use Only
Request date
(Application date)
Date mailed
Agency Rep
To protect your application date, we must receive this application by
.
(for agency use only)
What language do you speak best? English Spanish Vietnamese Other (specify) What language do you write best? English Spanish Vietnamese Other (specify)
If you do not speak English we can get interpreter services to help at no cost to you. If you need help to fill out this form, call your local Medicaid office or call us toll free at 1+888+544-7996. If you are deaf or have hearing problems, call the TTY line toll free at 1+800+220-5404.
This application is to get healthcare coverage for persons with disabilities who work and who are at
least age 16 but not yet age 65. If you want Medicaid for anyone else, check ( ) this . We will send you information about applying for other Medicaid coverage. Please fill out every item on this form. If an answer to a question is none or 0, write “none”. If you need more space for any item, use a separate sheet.
1.Tell us who YOU are, where YOU live, and where YOU get your mail:
Name
Parish
Home address
City
State
Zip code
Mailing address
Home phone ( )
Daytime phone (
)
2.Tell us about yourself and your spouse. You do not have to give your spouse’s Social Security number if he or she is not applying. If given, the number will only be used to verify assets.
You do not have to give race information. If you choose to do so, use the following codes: 1=White; 2=Black; 3=American Indian/Alaskan; 4=Asian; 5=Hispanic/Latino; 6=Hawaiian/Pacific Islander; 7=Hispanic/Latino & Other; 8=Multi-Race, Not Hispanic; 9=Unknown
Name - first, middle initial, last
Social Security
Date of birth
Sex
Race
US citizen/
Louisiana
Relation to you
number
Month
Day
Year
M/F
Legal alien
resident
Yes
No
self
spouse
3.Tell us about EACH job or business that you have. Show the amount of total or gross income before any deductions, not your take-home pay. (Send copies of pay check stubs or other proof of your earnings for last month. If you are self-employed, send copies of your most recent federal tax form with all schedule attachments. Send other proof if you do not have tax forms.)
Employer name, address & phone OR
Amount
How often do
# of hours
Self-employment information
paid
you get paid?
worked per week
$
4.Do you get any money like the kinds listed below? Yes No
Unemployment
Money from friends
Retirement/Pensions/Annuities
Workman’s Compensation
or relatives
Veteran’s Benefits
Interest/Dividends/Royalties
Any other not listed
(Show all money that you get and send proof of the income. You do not have to send proof of Social Security or Unemployment income.)
Income type
Source name,
How much
How often
address, & phone
do you get?
do you get it?
Have you ever applied for money from any of these sources? Yes No If Yes, when and from which ones?
5.Do you have Medicare or other health insurance? Yes No If Yes, answer the following. (Send proof of coverage and premium payment.)
Insurance company name,
Group/policy number
Monthly
Policy covers:
cost
hospital
doctor
ambulance
Can you get health insurance from your employer? Yes No
6.Do you, or you jointly with your spouse, have any assets or resources like those listed below? Yes No If Yes, give us the following information. (Send proof of ownership and value.)
Asset/Resource
Company name, address, & phone;
Value
Amount owed
Account number and/or description
Checking/Savings accounts (type)
Certificates of Deposit
Retirement accounts
Annuities/Trusts
Stocks/Bonds
Vehicles (if more than one)
Property, other than your home
Other (please be specific)
7.Did you ever apply for or get Social Security Disability or Supplemental Security Income (SSI)
benefits? Yes No If Yes, when?
Was a decision made? Yes No
If Yes, what was the decision?
8.What is your disability?
Tell us about the doctors or other medical providers who care for you:
Provider’s name(s)
Address & phone of this medical provider
9.Where did you find out about the Medicaid Purchase Plan?
Rights and Responsibilities
I declare that I am a U.S. citizen or in this country legally.
The information I gave on this form is true and correct to the best of my knowledge. I realize if I knowingly give information that is not true OR if I knowingly hold back information, I may get health benefits for which I am not eligible. If that happens, I can be lawfully punished for fraud. I may also have to pay Medicaid back for any medical bills which are paid incorrectly.
I understand that the information I give about my situation will be checked. I agree to help do that, and to let Medicaid get information it needs from government agencies, employers, medical providers, and other sources. If I refuse to help with this process or in later reviews caused by reported changes, or as part of a Recipient Eligibility review, it will mean that I can’t get Medicaid until I do help.
I know that Social Security numbers will only be used to get information from other government agencies to prove my eligibility.
I agree to tell Medicaid within 10 days if 1) I move out of state; 2) there are changes in where I live or get my mail; 3) there are any changes in other health insurance coverage; 4) there is any change in my work status.
By accepting Medicaid, I agree that any medical payments received from other sources will be sent to the Department of Health and Hospitals for any services that were covered by Medicaid.
I can ask for a Fair Hearing if I think the decision made on my case is unfair, incorrect or being made too late.
Medicaid can’t treat me differently because of my race, color, sex, age, disability, religion, nationality or political belief. If I think they have, I can call the U.S. DHHS Regional Office for Civil Rights in Dallas, TX at 1+800+368-1019 or write to Louisiana’s Department of Health & Hospitals, Human Resources at P. O. Box 1349 Baton Rouge, LA 70821-1349.
Signature of Applicant or Authorized Representative
Date
Signature of Agency Representative, if applicable
Completing the Care 1St Arizona Prior Authorization form is an essential step in securing healthcare coverage for individuals with disabilities. This process requires careful attention to detail, as each section of the form must be filled out completely to ensure that the application is processed smoothly. Below are the steps you should follow to accurately fill out the form.
After completing the form, review it carefully to ensure all sections are filled out accurately. Submit the form to the appropriate agency as instructed, and keep a copy for your records. This will help you track your application and follow up if necessary.
Filling out the Care 1St Arizona Prior Authorization form can be a straightforward process, but there are common mistakes that individuals often make. One frequent error is failing to complete every item on the form. Each section is important, and leaving any part blank can lead to delays in processing your application. If a question does not apply to you, simply write "none" to indicate that you have addressed it.
Another common mistake is not providing accurate contact information. Ensure that your home address, mailing address, and phone numbers are correct. This information is crucial for communication regarding your application. Additionally, if you have a spouse, be careful to include their details accurately, especially if they are applying alongside you.
Many people overlook the requirement to provide proof of income. When detailing your job or business, it is essential to include the total or gross income before any deductions. Remember to attach copies of your pay stubs or tax forms as required. Neglecting to do this can result in a denial of your application.
Another mistake is failing to report all sources of income. Be thorough when listing any money you receive, whether from Social Security, pensions, or even assistance from friends and family. Each source must be documented, and any income not reported could lead to complications later on.
Individuals often forget to include information about their health insurance. If you have Medicare or any other insurance, it’s important to provide the name of the insurance company and policy details. This information helps determine your eligibility and coverage options.
Not disclosing assets can also be problematic. If you or your spouse have any assets, such as savings accounts or property, these must be reported accurately. Failing to provide this information can lead to questions about your eligibility.
Another area where applicants stumble is in providing details about their disability. Clearly describing your disability and listing the medical providers who care for you is essential. This information helps establish your need for healthcare coverage.
Lastly, be mindful of the rights and responsibilities section. Failing to read and understand this part can lead to unintentional errors. Acknowledging your responsibilities, such as reporting changes in your situation, is vital for maintaining your eligibility.
By being aware of these common mistakes and taking care to avoid them, you can enhance the chances of a smooth application process for the Care 1St Arizona Prior Authorization form.