Do I qualify to apply?

Qualified applicants:

Are residents of Arizona.

Require ongoing assisted living services with assistance required with bathing, dressing, and toileting.

Do not qualify financially for Arizona Long Term Care Services.

Have total monthly income less than $6500 a month.

1. Name
2. Date of Birth
3. Male or Female
4. Marital Status
5. Spouses Name, Date of Birth if applicable
6. Home address
7. Mailing address, if different than home
8. Phone number
9. Email
10. Name of authorized representative and their relationship to applicant
11. Is applicant currently living at home, hospital, assisted living, or skilled nursing?
12. Does applicant own their own home? If so, do they have a mortgage? If so, what is the monthly payment, interest, and balance due on mortgage?
13. Is applicant renting? If so, what is the monthly rent and when does the lease expire?
14. What has been applicant’s average monthly income for last 12 months?
15. Has the applicant applied for ALTCS? If so, what was the outcome?
16. Does applicant need help with dressing or undressing? If so, for how long?
17. Does applicant need help with any aspects of toileting? If so, for how long?
18. Does applicant need help with bathing / showering? If so, for how long?
19. Does applicant need help preparing meals? If so, for how long?
20. How many times has the applicant fallen down in the last year? (A fall is defined as when one lands on the ground and did not intend to be there)
21. Is the applicant driving? If not, how long have they not been driving?
22. Please list all relevant medical diagnosis.
23. Attach copies of Power of Attorney, if applicable.
24. Attach medical records from PCP and relevant specialists.
25. Attach all bank, social security, investment account, and credit card statements for last year.
26. Social security number will be required if application accepted.