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Housing Application
AHCCCS Housing Programs
APPLICANT INFORMATION
Last Name
First Name
Middle Initial
Gender
Social Security Number
Phone Number:
Second Phone Number:
Email Address:
Do you use any other Social Security Number or Name(s)?
No Yes SSN: Name(s):
Date of Birth (MM/DD/YY)
Are you a citizen of the U.S?
Yes No
AHCCCS ID Number:
Title XIX (AHCCCS)
Yes No
Designation:
SMI GMH/SU
Are you a veteran?
Yes No
Please write in your Health Plan name:
Ethnicity
White
Black or African American
American Indian/Native Alaskan
Asian/Pacific Islander
Other
Hispanic
Non-Hispanic
Please check which GSA you would like to live:
Please check one or both Housing Types you wish to apply to:
Central
Southern
Northern
Scattered Sites (SS)
Community Living Program (CLP) (SMI Only)
Will family members be living in the household Yes No # of adults: # of children:
List any county preferences:
List any special housing type needs:
REFERRING AGENCY
Case Manager Name:
Provider Name:
Clinic/Health Home Site:
Provider Address:
Phone Number:
Email Address:
Identified Housing Need to be completed by approved representative:
Actual Homelessness
Institutional or Hospital Discharge
Other Identified Housing Crisis, please specify:
Fleeing domes
tic violence
Frequent hospitalization
Housing instability
All applications and questions can be sent to AHPapplications@azabc.org.
Applic
ant Signature: Date:
Agency Rep Signature: Date:
Agency
Rep Title:
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AUTHORIZATION FOR USE OR DISCLOSURE OF
PROTECTED HEALTH INFORMATION
Completion of this document authorizes the disclosures and/or use of individually identifiable health
information, as set forth below, consistent with Arizona and Federal law concerning the privacy of such
information. Failure to provide all information requested will invalidate this Authorization.
USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION
I hereby authorize the use and disclosure of my Protected Health Information (PHI) as follows:
Enrolled Member Name:
Persons/Organizations authorized to use or disclose the information:
• Arizona Behavioral Health Corporation (ABC)
• Arizona Health Care Cost Containment System (AHCCCS)
• HOM, Inc. (HOM)
• The Managed Care Organization with whom the member is enrolled.
• The service team, case manager, care coordinator or other designated housing supportive
service provider the member may be working with.
Purpose of the use or disclosure:
Information will be used to facilitate, manage and comply with State and Federal requirements
related to the Federal and/or State housing subsidy of the individual named above and to assist
the member in attaining and maintaining housing placement and subsidy support.
This Authorization applies to the following information
Name, AHCCCS enrollment and enrollment in RBHA or any successor corporation that contracts
with the State of Arizona to provide behavioral health services in Arizona, verification of Serious
Mental Illness diagnosis and information required to verify eligibility and prioritization for the
housing program.
EXPIRATION
This authorization will expire one year from the date this document is signed below.
RESTRICTIONS
This Authorization may not be used to release Substance Abuse or Confidential Communicable Disease/1-
IIV information in combination with any other health care information. Federal law requires a specific
Authorization be used for the disclosure of this information.
If we share you PHI with the people or agencies that you name, they may share it with others if allowed
under the law.
YOUR RIGHTS
Note: This form may not be used to release psychotherapy notes in combination with other types of
health information (45 CFR § 164.508(b)(ii). If this form is being used to authorize the release of
psychotherapy notes, a separate form must be used to authorize release of any other Protected Health
Information.
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I understand that I may refuse to sign this Authorization. My refusal to sign will not affect my ability to
obtain, treatment, payment, or my eligibility of benefits. I may inspect or copy any information used or
disclosed under this Authorization, unless the information is contraindicated as determined by my
psychiatrist. I do understand that my refusal to sign may prevent me from participation in any in any
housing program administered by ABC.
I may revoke this Authorization at any time. My revocation must be in writing, signed by me or on my
behalf by an authorized representative. My revocation will be effective upon receipt but will not be
effective to the extent that the Requesting Party or others have acted in reliance upon this Authorization.
I do understand that my revocation may prevent me from continued participation in any housing
program administered by ABC.
I have a right to receive a copy of this Authorization.
MEMBER SIGNATURE
S
ignature: ________________________________________
Enrolled Member/Representative/Guardian
D
ate: ________________________________________
If signed by someone other than the Enrolled Member, state your relationship to the Member:
________________________________________
REFERRING AGENCY SIGNATURE
Name: ________________________________________
Title:
________________________________________
Date:
________________________________________