CSO-2399B

(02/21)

ARIZONA DEPARTMENT OF CHILD SAFETY

BENEFITS SCREENING TOOL

Instructions: Please complete Part I and answer all questions as applicable by putting a check mark in the appropriate box. Sign and date form.

Part I - Applicant

Applicant’s Name (Last Name, First Name) Date of Birth AFF Referral Date

Social Security Number: No. of Permanent Household Members: County

Are you on AHCCCS? Yes No

AHCCCS ID No.

Do you have an AHCCCS application pending? Yes No

Are you married or planning to be married or separated and attempting to reconcile? Yes No

Is your family currently receiving Temporary Cash Assistance/TANF? Yes No

If yes,

DES/Jobs Case Manager Name Phone

What is your total gross monthly or annual family income? or

Monthly Annually

Do you have health or medical insurance? Yes No

If yes, name of insurance provider:

Insurance Provider

I declare that this information is correct to the best of my knowledge.

Applicant’s Signature Date

Part 2 - Provider Use Only

Instructions: Original maintained in client case record. This form must be updated as changes occur.

The applicant is enrolled in Title XIX or XXI services. Yes No

The applicant may be eligible for Title XIX or XXI services. Yes No

The applicant is not eligible for Title XIX or XXI services. Yes No
CSO-2399B
(02/21)
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ARIZONA DEPARTMENT OF CHILD SAFETY
BENEFITS SCREENING TOOL

Part 3 - Income Guidelines (Effective 2/1/2020)

Adults age 18+
Is the person:
Pregnant? Yes No
Age 65 or older? Yes No
Blind or disabled? Yes No
Receiving Social Security disability benefits Yes No
Receiving Medicare benefits? Yes No
Been determined to have a Serious Mental Illness by AHCCCS/T/RBHA? Yes No
If so, and the person’s family income is equal to/below the following amounts, the person may be AHCCCS (Title XIX) eligible. Assist the person in
completing an AHCCCS application.

Family Size 1 2 3 4 5 6
Gross Monthly $1,659 $2,242 $2,824 $3,406 $3,989 $4,571
Family Income*

If none of the above conditions apply, is the person’s family income equal to/below the following amounts? Yes No
(These income limits also apply for children 6-18 years of age. Limits are slightly higher for younger children—see AHCCCS guidelines for applicable
income limits).
If yes, the person may be AHCCCS (Title XIX) eligible. Assist the person in completing an AHCCCS application. Only the gross income and number
of child(ren) and the child(ren)’s parent(s) or relative caregiver(s) living in the home are counted.

Family Size 1 2 3 4 5 6
Gross Monthly $1,415 $1,911 $2,408 $2,904 $3,401 $3,897
Family Income*
*For each additional member add $583 **For each additional member add $497

Signatures

Provider Staff Signature: Date Form Completed

CSO-2399B
(02/21)
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ARIZONA DEPARTMENT OF CHILD SAFETY
BENEFITS SCREENING TOOL

Completion Guide
This tool assists in determining appropriate funding sources. Participants are not to be screened out of Arizona Families F.I.R.S.T. based on income.
Part I: To be completed by client
The provider shall assist the client in completing Part I of the tool during the initial intake. If the client has difficulty understanding the screening tool,
the provider shall assist in its completion. The client shall sign and date the tool. The screening tool should be revised as eligibility changes.
Parts II, III: To be completed by Provider
The provider shall complete all questions in Part II and III, following completion of Part I by the client, to screen for Title XIX eligibility.
Part IV: To be completed by Provider
The provider shall complete the questions in Part IV to determine client eligibility for non-Title XIX grant funded services only if the client does
not qualify for Title XIX services (Parts I, II and III). Depending on client characteristics and circumstances, any of the non-Title XIX grants may
be possible sources of funding. These should be pursued through the RBHA/TRBHA that services the county of the client's residence before
DCS AFF State funding is accessed.
The completed and signed form shall be maintained in the client's case record.

Equal Opportunity Employer/Program. The Department of Child Safety (DCS) prohibits discrimination in admissions,
programs, services, activities, or employment based on race, color, religion, sex, national origin, age, disability, genetics,
or retaliation or any other status protected by federal law, state law, or regulation. Reasonable accommodations to
allow a person with a disability to take part in a program, service, or activity are available upon request. To request
this document in alternative format or for further information about this policy contact your local office. TTY/TDD
Services: 7-1-1. Free language assistance for DCS services is available upon request. Ayuda gratuita con traducciones
relacionadas con los servicios del DCS esta disponible a solicitud del cliente.