Section R9-6-404. Initial Application Process

A.      An applicant for initial enrollment in ADAP or the applicant’s representative shall submit to the Department the following documents:

1.        A Department-provided form, completed by the applicant or the applicant’s representative containing:

a.        The applicant’s name, date of birth, and gender;

b.        Except as provided in subsection (A)(1)(c), the applicant’s residential address and mailing address;

c.        If the applicant is in non-permanent housing, the address of a community service organization that has agreed to receive written communications for the applicant;

d.        If applicable, the name of the applicant’s representa- tive and the mailing address of the applicant’s repre- sentative, if different from the applicant’s mailing address;

e.        The telephone number of the applicant or a person that has agreed to receive telephone communications for the applicant;

f.         The number of individuals in the applicant’s family unit and the names and ages of the individuals;

g.        The names of individuals, other than the persons specified in subsection (A)(1)(q)(iii), with whom the applicant authorizes the Department to speak about the applicant’s enrollment in ADAP;

h.        The applicant’s annual family income;

i.         The applicant’s race and ethnicity;

j.         Whether the applicant or an adult in the applicant’s family unit:

i.         Is employed;

ii.        Is self-employed;

iii.      Is receiving public assistance;

iv.      Is receiving regular monetary payments from a source not specified in subsection (A)(1)(j)(i) through subsection (A)(1)(j)(iii) and, if so, an identification of the source of the monetary payments; or

v.        Is using a source not specified in subsection (A)(1)(j)(i) through subsection (A)(1)(j)(iv) or savings to assist the applicant in obtaining food, water, housing, or clothing for the appli- cant and if so, an identification of the source;

k.        Whether the applicant is receiving benefits from AHCCCS;

l.         The date the applicant or the applicant’s representa- tive is scheduled to meet with AHCCCS to discuss eligibility for AHCCCS, if applicable;

m.      Whether the applicant is eligible for Medicare bene- fits and, if not, the date on which the applicant will be eligible for Medicare benefits;

n.        If the applicant is eligible for Medicare benefits, whether:

i.         The applicant or the applicant’s representative has applied for a low-income subsidy for the applicant and, if so, the date of the application for the low-income subsidy; and

ii.        Either:

(1)     The applicant or the applicant’s representative has applied for a Medicare drug plan for the applicant and, if so, the date of the application for the Medicare drug plan; or

(2)     The applicant is enrolled in a Medicare drug plan;

o.        Whether the applicant has health insurance other than Medicare that would pay for drugs on the ADAP formulary;

p.        Whether the applicant has served on active duty:

i.         In the U.S. Air Force, Army, Coast Guard, Marine Corps, or Navy;

ii.        In the Army National Guard or Air National Guard; or

iii.      As a reservist serving on active duty other than for routine training purposes;

q.        A statement by the applicant or the applicant’s repre- sentative confirming that the applicant or the appli- cant’s representative:

i.         Understands that the applicant or the appli- cant’s representative is required to submit to the Department proof of ineligibility for enrollment in AHCCCS and for a low-income subsidy within 30 calendar days after the date of appli- cation, if not provided to the Department with the application;

ii.        Understands that the applicant or the appli- cant’s representative is required to submit to the Department proof of enrollment in a Medicare drug plan, if the applicant is eligible for Medi- care, within 30 calendar days after the date of application, if not provided to the Department with the application;

iii.      Grants permission to the Department to discuss the information provided to the Department under subsection (A) with:

(1)     AHCCCS, for the purpose of determining AHCCCS eligibility;

(2)     Medicare and the Social Security Admin- istration, for the purpose of determining eligi- bility for a low-income subsidy and enrollment in a Medicare drug plan;

(3)     The applicant’s primary care provider or designee;

(4)     The vendor pharmacy, to assist with drug distribution; and

(5)     Any other entity as necessary to establish eligibility for enrollment in ADAP or assist with drug distribution to the applicant;

iv.      Understands that the applicant or the appli- cant’s representative is required to submit to the Department proof of annual family income as part of the application; and

v.        Understands that the applicant or the appli- cant’s representative is required to notify the Department of changes specified in R9-6- 406(A);

r.         A statement by the applicant or the applicant’s repre- sentative attesting that:

i.         To the best of the knowledge and belief of the applicant or the applicant’s representative, the information provided to the Department as specified in subsection (A), including the infor- mation in the documents accompanying the form specified in subsection (A)(1), is accurate and complete;

ii.        The applicant meets the eligibility criteria spec- ified in R9-6-403; and

iii.      The applicant or applicant’s representative understands that eligibility does not guarantee that the Department will be able to provide drugs and understands that an individual’s enrollment in ADAP may be terminated as specified in R9-6-408; and

s.        The dated signature of the applicant or the appli- cant’s representative;

2.        The Department-provided form specified in subsection (B), completed by the applicant’s primary care provider;

3.        A written prescription order signed by the applicant’s pri- mary care provider or a copy of the written prescription order for each drug on the list specified in subsection (B)(5);

4.        A copy of current documentation from AHCCCS stating that the applicant’s eligibility for enrollment in AHCCCS has not yet been determined or that AHCCCS is denying eligibility to the applicant;

5.        If the applicant is eligible for Medicare, a copy of current documentation from the Social Security Administration stating that the applicant’s eligibility for a low-income subsidy has not yet been determined or that the applicant is ineligible for a full low-income subsidy;

6.        If the applicant is eligible for Medicare, a copy of the applicant’s Medicare prescription card or copy of a letter from the company providing the applicant’s Medicare drug plan, confirming that the applicant has applied for or is enrolled in a Medicare drug plan;

7.        Proof of annual family income, including the following items as applicable to the applicant’s family unit:

a.        For each job held by an adult in the family unit:

i.         Paycheck stubs from the 30 calendar days before the date of application, or

ii.        A statement from the employer listing gross wages for the 30 calendar days before the date of application;

b.        From each self-employed adult in the family unit, documentation of the current net income from self- employment, such as:

i.         An income tax return submitted for the previ- ous tax year to the U.S. Internal Revenue Ser- vice or the Arizona Department of Revenue;

ii.        The Internal Revenue Service Forms 1099 pre- pared for the previous tax year for the self- employed adult in the family unit;

iii.      A profit and loss statement for the self- employed adult’s business; or

iv.      Bank statements from the self-employed adult’s checking and savings accounts;

c.        A letter from each entity providing public assistance to an adult in the family unit, describing payments from public assistance;

d.        A letter from an entity providing a monetary award to an adult in the family unit to cover educational

	expenses other than tuition, describing the monetary		vi.   A homeowners’ association assessment or fee
	award; and		statement, dated within 60 calendar days before
	e.      Documentation showing the amount and source of		the date of application;
	any regular monetary payments received by an adult		vii.  A current lease agreement; or
	in  the  family  unit  from sources  other than  those		viii. A mortgage statement for the most recent tax
	specified in subsection (A)(7)(a) through subsection		year;
	(A)(7)(d);	b.	If the applicant is unable to produce documentation
8.	If the applicant or the applicant’s representative has stated		that satisfies subsection (A)(9)(a), two of the follow-
	on the form specified in subsection (A)(1) that the appli-		ing   that  show   the   Arizona   residential   address
	cant has no source of regular monetary payments and is		included on the Department-provided form specified
	unable to provide any of the documentation specified in		in subsection (A)(1) and the name of the applicant or
	subsection  (A)(7),   a  Department-provided  form,  com-		an adult in the applicant’s family unit:
	pleted and signed within 30 calendar days before the date		i.      A  utility  bill  dated  within  60   calendar  days
	of application, containing:		before the date of application;
	a.     Information completed by the applicant or the appli-		ii.     A tax statement, other than a property tax state-
	cant’s representative stating whether:		ment, issued by a governmental entity for the
	i.      An adult in the applicant’s family unit receives		most recent tax year;
	money from intermittent work performed by		iii.   An Internal Revenue Service Form W-2 for the
	the adult in the family unit for which no pay-		most recent tax year;
	check stub is received and, if so, the average		iv.    A  check  stub  or   statement  of  direct   deposit
	monthly earnings, and the adult’s occupation;		issued by an employer for the most recent pay
	ii.     The applicant is homeless or living in a shelter;		period;
	iii.   The  applicant   is  receiving   assistance  from		v.     A bank or credit union statement dated within
	another individual; and		60 calendar days before the date of application;
	iv.    The applicant has another source of assistance		vi.   A non-expired Arizona driver license issued by
	for obtaining food, water, housing, and cloth-		the  Arizona   Department  of  Transportation’s
	ing, and, if so, an identification of the source;		Motor Vehicle Division;
	b.     A statement by the applicant or the applicant’s repre-		vii.  A  non-expired  Arizona  vehicle  registration
	sentative attesting that to the best of the knowledge		issued by the Arizona Department of Transpor-
	and belief of the applicant or the applicant’s repre-		tation’s Motor Vehicle Division;
	sentative, the information submitted under subsec-		viii. A    non-expired   Arizona   identification   card
	tion (A)(8)(a) is accurate and complete;		issued by the Arizona Department of Transpor-
	c.      The dated signature of the applicant or the appli-		tation’s Motor Vehicle Division;
	cant’s representative;		ix.   A tribal enrollment card or other type of tribal
	d.     A statement by the applicant’s case manager or pri-		identification; or
	mary care provider attesting that to the best of the		x.     A   current   immigration   identification   card
	knowledge and belief of the applicant’s case man-		issued  by  U.S.  Citizenship   and  Immigration
	ager or primary care provider the information sub-		Services; or
	mitted under subsection (A)(8)(a) is accurate and	c.	If the applicant is unable to produce documentation
	complete; and		that satisfies either subsection (A)(9)(a) or (b), two
	e.     The dated signature of the applicant’s case manager		of the following that include the name of the appli-
	or primary care provider;		cant or an adult in the applicant’s family unit:
9.	Proof  that  the  applicant   is  a  resident  of   Arizona  that		i.      A  document  listed   in subsection (A)(9)(b)(i)
	includes:		through subsection (A)(9)(b)(x) that includes
	a.     One of the following that shows the Arizona resi-		the Arizona residential address shown on the
	dential  address  included  on  the   Department-pro-		Department-provided form specified in subsec-
	vided form specified in subsection (A)(1) and the		tion (A)(1);
	name of the applicant or an adult in the applicant’s		ii.     A letter issued by an entity providing non-per-
	family unit:		manent housing to the applicant, including the
	i.      Documentation issued by a governmental entity		Arizona residential address of the non-perma-
	related  to  participation   in  public  assistance,		nent housing that is the same as the Arizona
	dated within 60 calendar days before the date of		residential address for the applicant shown on
	application;		the Department-provided form specified in sub-
	ii.     Current documentation from AHCCCS related		section (A)(1);
	to the applicant’s eligibility for enrollment in		iii.   A written statement issued by a community ser-
	AHCCCS;		vice organization, verifying that the applicant is
	iii.   Current documentation from the Social Secu-		homeless and a resident of Arizona;
	rity Administration or the Department of Veter-		iv.    A credit card, primary care provider’s office,
	ans Affairs related to the applicant’s eligibility		insurance company, or mobile telephone com-
	for benefits;		pany billing statement dated within 60 calendar
	iv.    Current    documentation   from   the    Arizona		days before the date of application, including
	Department of Economic Security related to the		the Arizona residential address shown on the
	applicant’s eligibility for unemployment insur-		Department-provided form specified in subsec-
	ance benefits;		tion (A)(1);
	v.     A property tax statement for the most recent tax
	year issued by a governmental entity;

v.                 A current vehicle insurance card, including the Arizona residential address shown on the Department-provided form specified in subsec- tion (A)(1);

vi.               An official document, such as an Arizona voter registration card, issued by a governmental entity and including the Arizona residential address shown on the Department-provided form specified in subsection (A)(1);

vii.             A written statement issued by the applicant’s case manager indicating that the case manager has conducted a home visit with the applicant at the Arizona residential address shown on the Department-provided form specified in subsec- tion (A)(1) within 30 calendar days before the date of application; or

viii.           A written statement issued by the applicant’s primary care provider, verifying that the appli- cant is a resident of Arizona; and

10. If the applicant or the applicant’s representative has stated on the Department-provided form specified in subsection (A)(8) that the applicant receives assistance from another individual, a letter from the individual to support the statement of the applicant or the applicant’s representa- tive.

B.       The primary care provider of an applicant for initial enroll- ment in ADAP shall complete for the applicant a Department- provided form containing:

1.        The applicant’s name;

2.        The primary care provider’s name, business address, tele- phone number, fax number, and professional license number;

3.        A statement that the applicant has been diagnosed with HIV infection;

4.        The dates of and results for the most recent confirmatory test, CD4-T-lymphocyte count, and, if available, viral load test conducted for the applicant;

5.        A list of each drug from the current ADAP formulary pre- scribed for the applicant by the primary care provider;

6.        A statement by the primary care provider that the primary care provider understands that the primary care provider is required to notify the Department of changes specified in R9-6-406(B);

7.        A statement by the primary care provider attesting that, to the best of the primary care provider’s knowledge and belief, the information provided to the Department as specified in subsection (B) is accurate and complete; and

8.        The dated signature of the primary care provider.

C.      For purposes of enrollment in ADAP, an applicant or the appli- cant’s representative may report annual family income using actual family income for the most recent 12 months or esti- mated annual family income determined by multiplying the most recent monthly family income by 12.

Historical Note

Adopted as an emergency effective January 12, 1988, pursuant to A.R.S. § 41-1026, valid for only 90 days (Supp. 88-1). Emergency expired. Readopted without change as an emergency effective May 9, 1988, pursuant to A.R.S. § 41-1026, valid for only 90 days (Supp. 88-2).

Amended and readopted as an emergency effective August 8, 1988, pursuant to A.R.S. § 41-1026, valid for only 90 days (Supp. 88-3). Emergency expired.

Readopted as an emergency and subsection (A) corrected effective November 16, 1988, pursuant to A.R.S. § 41-

1026, valid for only 90 days (Supp. 88-4). Emergency expired. Amended subsection (B) and adopted as a per-

manent rule effective May 22, 1989 (Supp. 89-2). Renumbered from R9-6-804 and amended effective October 19, 1993 (Supp. 93-4). Former Section R9-6-404 renumbered to R9-6-405; new Section R9-6-404 renum- bered from R9-6-403 and amended by final rulemaking at 8 A.A.R. 1953, effective April 3, 2002 (Supp. 02-2).

Amended by final rulemaking at 13 A.A.R. 3329, effec- tive November 10, 2007 (Supp. 07-3).