Required Documentation for Arizona State Primary Care Program Federal

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Required Documentation for Arizona State Primary Care Program Federal Powered By Docstoc
					                                                  Required Documentation for

                                             □    Arizona State Primary Care Program
                                                 □ Federal Sliding Fee Scale Program
     I. Verification of Income (One months’ proof of income- any of the following that apply)
               Pay Stub(s) for the last month (for all income for the household) OR
               Letter (on Company letterhead) from the Employer stating the following:
                         1. Employee’s name, address and phone number
                         2. Gross income for the last month
                         3. Supervisor’s name and signature
               Income Tax Return for previous year if self-employed (Forms 1040, SE, Schedule C (or F for Farm Owners)).
               Proof of business income and the expenses for the last calendar month.
               Income determination worksheet (current) produced by D.E.S., W.I.C., or other state agency and signed by
               Retirement Income (Medicare, Pension, SDI, etc.)
               Unemployment letter (from Unemployment Office)
               Child support
               Public assistance letter if receiving (AFDC, General Assistance, AHCCCS, Social Security, etc.)
               In-Kind earnings (such as anyone who receives free rent for services)

     II. AHCCCS Status
               AHCCCS Denial letter is required, if not receiving AHCCCS benefits
               Ineligible Applicants need to sign an AHCCCS ineligibility form

     III. Verification of Arizona/ United States Residence (with your name and address) One of the following:
               Current Utility bill, Rent, Mortgage or Lease receipt in the client’s name showing physical Arizona address – no
               P.O. Box.
               U.S. Post Office record showing a physical Arizona address – no P.O. Box
               Letter from neighbor (not a relative) Verifying your physical address, signed by the person along with their address

     IV. Verification of dependants and self
               Government issued identification (Valid Arizona Driver’s license, Arizona ID card or Passport)
               Birth Certificates or Baptismal Records, Marriage Certificate (if applicable)
               Social Security cards for client and all dependents (if applicable)
               Citizenship- citizenship or immigration documents for persons who were not born in the US or its territories.
               Legal documents proving guardianship for children that are in your custody

    VI. Insurance Information- If you have insurance, bring your insurance card(s) with you.

         Mobile Medical Unit                       Bisbee                    Douglas                  Cliff Whetten Clinic
             1100 ‘F’ Avenue                  108 Arizona Street           1100 ‘F’ Avenue               10566 Highway 191,
            Douglas, AZ 85607                 Bisbee, AZ 85610            Douglas, AZ 85607         P.O. Box 263, Elfrida, AZ 85610
            (520) 364-4984                  Phone: (520) 432-3309       Phone: (520) 364-3285           Phone: (520) 642-2222
          FAX: (520) 805-1292                FAX: (520)432-3717          FAX: (520)364-3378              FAX: (520) 642-3591
                                                                    (from Willcox call: 384-6300)   (from Willcox call: 384-6363)

Revised: 09/2009 Eligibility CQI Team III                                                                               Section 2 Page 5