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CUSTOMER NAME: |
DATE: 06/03/2015 |
HEAPLUS PERSON ID: 39900331255121 |
APPLICATION ID: 201405506035 |
Call 602-417-5010 if you have any questions or need helpAnthony OConnell
439 S Vista Del Rio
Green Valley, AZ 85614-2415
Request for Information
Dear Anthony OConnell,
We need the infornation listed below to decide if you can qualify for the programs for which you have applied. Contact us if you have trouble getting the information we are requesting. We may be able to help.
You must give us this infonnation no later than 06/18/2015. There are several ways for you to give us the infonnation we are asking for below:
1. Log in to your Health-e-Arizona Plus account at 'www.healthearizonaplus.gov' to scan. upload. or email information. or
2. Fax your information using the attached fax coversheet to 1-888-372-8777. The fax coversheet has a barcode that identifies your case. or
3. Mail your infonnation to: AHCCCS. 801 E. Jefferson street. MD 3800, Phoenix, AZ 85034
If you cannot get this information to us by the due date, you may be able to get more time. You can request more time by calling the number above.
If we do not get the information and we do not hear from you. we will deny your application or stop/change your benefits.
15597140000005090100005
[Page 2 of 11]
CUSTOMER NAME: |
DATE: 06/03/2015 |
HEAPLUS PERSON ID: 39900331255121 |
APPLICATION ID: 201405506035 |
+ -Medical Assistance
We need to verify... |
Please give us... Note: The following are common examples of the documents and information that we can use. Please send any proof you have, even if it is not listed in these examples. |
Required by 6/18/2015 for |
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A copy of one of the following
We have attached the following form(s) that may help you:
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X |
|
We have attached the following form(s) that may help you:
|
X |
Must apply for Civil Service , Retirement Annuities, or pensions
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You may qualify for this benefit. You must contact the organization or agency to apply for benefits.
We have attached the following form(s) that may help you:
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X |
Must apply for Veteran's Benefits
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You may qualify for this benefit. You must contact the Veteran's Administration to apply for benefits. To apply:
After applying, give us:
We have attached the following form(s) that may help you:
|
X |
[Page 3 of 11]
CUSTOMER NAME: |
DATE: 06/03/2015 |
HEAPLUS PERSON ID: 39900331255121 |
APPLICATION ID: 201405506035 |
15597140000005090200005
[Page 4 of 11]
CUSTOMER NAME: |
DATE: 06/03/2015 |
HEAPLUS PERSON ID: 39900331255121 |
APPLICATION ID: 201405506035 |
Request for Verification of Unearned Income
Please mail, fax or e-mail this completed form to us WITHIN 10 DAYS. The information you give us will be kept confidential except when we are required by law to release the information.
Please give us the information listed below from to
Information Requested About |
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| Name: | Social Security Number: | ||
| SOURCE OR TYPE OF INCOME | GROSS AMOUNT | DATE ISSUED | TIME PERIOD COVERED (MONTH, WEEK) |
| 1. Will the payment amount change because of a cost of living adjustment? | No Yes | When? | |
| 2. Will the payment amount ever change because of another reason? | No Yes | When? | |
| 3. Is the person charged a fee to obtain the income? | No Yes | ||
| If yes, what Is the type of fee and amount? | Type: Amount: | ||
| 4. Is the person receiving the maximum payment available? | No Yes | ||
| If no, What is the maximum payment available? | |||
| 5. Does the person have medical Insurance? | No Yes | Policy #: | |
| What is the effective date of coverage? | |||
| Which family members are covered? | |||
| What is this person's portion of the premium amount? | |||
| What is the Insurance company's name and phone number? | |||
| 6. Does the person have any life insurance policies? | No Yes | Policy #: | |
| What is the insurance company's name and phone number? | |||
| Company Representative's Signature: | Title: | Phone #: | Date: |
15597140000005090200005
[Page 5 of 11]
CUSTOMER NAME: |
DATE: 06/03/2015 |
HEAPLUS PERSON ID: 39900331255121 |
APPLICATION ID: 201405506035 |
Referral for Veteran's Benefits
Referral Information |
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To qualify for AHCCCS Medical Assistance or Cash Assistance, a person who may be eligible for Veterans Benefits must apply for those benefits. We have determined that you may be eligible for Veterans Benefits You may apply for Veteran's Benefits in person or online. When applying for benefits in person, take this notice to the VA and ask the person who accepts your application to complete the bottom portion of this form. If you apply online, print a copy of the electronic confirmation that your application has been sUbmitted. Return the completed form or confirmation of online application to the address shown above no later than:
IF YOU DO NOT APPLY FOR VETERANS BENEFITS, WE WILL DENY YOUR APPLICATION |
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| Veteran's Name: | SSN: | Date of Birth: | |
| Veteran resides in a Nursing Facility? Yes No | Customer requesting augmented payments? Yes No | ||
| Customer is: Unmarried Total income: _ Married Total income of customer and spouse: |
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REMINDER: You may be required to provide the information listed below: |
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VA Response Section |
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| The sections below are to be completed by the VA Representative. Please check the appropriate boxes, sign, date and return to the address listed at the top of this letter, by the date shown above. __ This is to verify that the person named at the top of this letter applied for Veterans Benefits on __ This is to verify that the person named at the top of this letter receives the maximum VA benefits for which the person is entitled. Reason for Ineligibility If the person named above is ineligible for Veteran's Benefits, please check the box below that indicates the reason(s) for denial: __ Customer is a Veteran who states he is not disabled. __ Customer is a Veteran who is not totally disabled. __ Customer is a Veteran who did not have wartime service. __ Customer is the survivor of a Veteran who did not have wartime service. __ Customer is the dependent of a living Veteran who does not receive Veteran's Benefits. __ Other: _ |
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| Does the veteran own GI Life Insurance? __ Yes __ No Policy #: ________ Face value _______ Cash Value _______ | |||
| Agency Representative's Signature | Title | Phone Number | Date |
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[Page 6 of 11]
CUSTOMER NAME: |
DATE: 06/03/2015 |
HEAPLUS PERSON ID: 39900331255121 |
APPLICATION ID: 201405506035 |
Referral for Potential Benefits
Referral for Potential Benefits |
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| To qualify for AHCCCS Medical Assistance or Cash Assistance, a person who may be eligible for certain other types of benefits must apply for those benefits. We have determined that you may be eligible for: When you apply in person, take this form to the appropriate agency and ask the person who accepts your application to complete the bottom portion of this form. If you apply online, print a copy of the electronic confirmation that your application has been submitted. Return the completed form or confirmation of online application to the address shown above no later than: [DATE] IF YOU DO NOT APPLY FOR THESE BENEFITS, WE WILL DENY YOUR APPLICATION OR STOP YOUR ONGOING AHCCCS MEDICAL ASSISTANCE OR CASH ASSISTANCE. |
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| Name: | SSN: | Date of Birth: | |
| This section is to be completed by the agency accepting the application. Please sign, dare and return to the address shown at the top of this form. | |||
This is to verify that the above named person applied for _____________ (type of benefit) on _____________ (date). |
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| Agency Representative's Signature | Title: | Phone Number: | Date: |
15597140000005090600005
[Page 7 of 11]
Fax Cover Sheet
Permanent Documents
Application ID 201405506035
______________________________________________________________________________________
Primary Informant Anthony OConnell Date: 06/03/2015
Other Persons
Address 439 S. Vista Del Rio, Green Valley, Arizona 85614 2415
PhoneFax Cover Sheet Instructions
In order to fax documents to HEAplus, you must use this HEApius Fax Cover Sheet. The barcodes on this Fax Cover Sheet attach the faxed documents to the application (application 10 listed above). Examples of acceptable documents are provided on the following pages.
Please mark. an "X" in the check box next to each document you are faxing. Example X
Please remember to include the proof documents along with this Fax Cover Sheet 1-888-372-8777 OR 1-916-515-5043
Documents Attached
NO PERMANENT DOCUMENTS REQUIRED
See faxing instructions on pages following the fax cover sheets.
HIXPUBPERM
201405506035
15597140000005090800005
[Page 8 of 11]
Fax Cover Sheet
Temporary Documents
Application ID 201405506035
______________________________________________________________________________________
Primary Informant Anthony OConnell Date: 06/03/2015
Other Persons
Address 439 S. Vista Del Rio, Green Valley, Arizona 85614 2415
PhoneFax Cover Sheet Instructions
In order to fax documents to HEAplus, you must use this HEApius Fax Cover Sheet. The barcodes on this Fax Cover Sheet attach the faxed documents to the application (application 10 listed above). Examples of acceptable documents are provided on the following pages.
Please mark. an "X" in the check box next to each document you are faxing. Example X
Please remember to include the proof documents along with this Fax Cover Sheet 1-888-372-8777 OR 1-916-515-5043
Documents Attached
__ Income (Anthony OConnell)
__ Application for Potential Pension Benefits (Anthony OConnell)
__ Application for Veteran's Benefits (Anthony OConnell )
See faxing instructions on pages following the fax cover sheets.
HIXPUBPERM
201405506035
15597140000005090800005
[Page 9 of 11]
CUSTOMER NAME: |
DATE: 06/03/2015 |
HEAPLUS PERSON ID: 39900331255121 |
APPLICATION ID: 201405506035 |
Request for Verification of VA Information
| II. To be completed by the Veterans Administration | ||||||
| Please show the month and year in which VA benefits were actually paid to the persons named on page 1 of this form, not when payments were due. If more than one type of VA payment is made to the same person, please enter all requested information for each type of VA payment separately. Please use additional sheets, if needed. |
||||||
| A. Type of VA Payment | __ Pension based on need __Reduced Pension __Compensation based on need __ Pension not based on need __Compensation not based on need |
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| B. Frequency of Pay | If frequency is other than monthly for D, E, For G below, please show the month in which the benefit was paid. __Monthly __Annually __Other |
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| C. Total of VA Payment | All attributable to aid and attendance or housebound allowance? __Yes __NO If no, indicate amount attributable to aid and attendance or housebound allowance |
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| D. Basic monthly VA payment amount of VeteranlWidow(er)/Dependent Parent (exclude Aid and Attendance, Educational stipend, Housebound, Dependencv allowances or unusual medical expenses) |
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| Amount | Effective Date of Current Payment | End Date of Current Payment | ||||
| E. Educational Benefit (Stipend/Vocational Rehabilitation/Government FundedNeteran's Contribution) | ||||||
| Type | Amount | Effective Date of Current Payment | End Date of Current Payment | |||
| F. Amount of VA Payment Attributable to Dependent(s) | ||||||
| Name of Dependent | Amount | Paid to Dependent? | Effective Date of Current Payment | End Date of Current Payment | ||
| G. Amount of VA payment attributable to Unusual Medical Expenses. | ||||||
| Amount | Effective Date of Current Payment | End Date of Current Payment | ||||
| Lump Sum: | ||||||
| Recurring Increase: | ||||||
| H. Clothing Allowance Date Amount | ||||||
| I. Amounts Withheld to Recover a VA Overpayment (CP). | ||||||
| Name | Amount of OP | Period of OP | Rate of Recovery | Period of Recovery | ||
| From Mo/Yr |
Through Mo/Yr |
From Mo/Yr |
Through Mo/Yr |
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| J. Retroactive VA Payment | ||||||
Name |
Amount |
Paid in Month/Year |
||||
| K. Does the veteran own GI Life Insurance? __ Yes __ No Policy #: Face Value: Cash Value: | ||||||
| Signature | Time | Date | ||||
[Page 10 of 11]
CUSTOMER NAME: |
DATE: 06/03/2015 |
HEAPLUS PERSON ID: 39900331255121 |
APPLICATION ID: 201405506035 |
Request for Verification of VA Information
| Name of Claimant | Veteran's Name | Veteran's Social Security Number |
| Service Serial Number | Veteran's Date of Birth | VA Claim Number |
Please mail, fax or bring this completed form within 10 days. The information you give us will be kept confidential except |
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| __The veteran | __The dependent(s)/survivor(s) of the veteran | ||
| Name | Relationship to Veteran | Months in which Payments Were Made |
|
From Month/Year |
Through Month/Year |
||
| Remarks: | |||
[Page 11 of 11]
CUSTOMER NAME: |
DATE: 06/03/2015 |
HEAPLUS PERSON ID: 39900331255121 |
APPLICATION ID: 201405506035 |
Request for Verification of VA Information
15597140000005090500005