DDD-1972A - Application for Eligibility Determination - Packet 2026

1. Click ‘Get Form’ to open the DDD-1972A application in the editor.
2. Begin with SECTION A, where you will enter the applicant's information. Fill in the name, date of birth, AHCCCS A Number (if applicable), primary language, sex, home address, and contact details.
3. In SECTION B, provide details about the parent or foster parent if applicable. Include their name, phone number, address (if different), and relationship to the applicant.
4. Proceed to SECTION C to document health insurance information. Enter the type of coverage, health plan name, policy holder’s name and ID/Group number.
5. If applicable, complete SECTION D by detailing early intervention and educational history. List any programs attended along with dates.
6. Finally, review all sections for accuracy before signing at the end of the form. Ensure that all required documentation is attached before submission.

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