LEAVE REQUEST FORM/AUTHORIZATION - United States Navy
$10 - $70 monthly premium covers all eligible children AHCCCS Medical Services2 Coverage for Individuals Parent & Caretaker Relatives www.healthearizonaplus.gov or DES/Family Assistance Office Call 1-855-HEA-PLUS for the nearest office 106% FPL 1 $1,104 2 $1,494 3 $1,885 4 $2,275 Add $390 per Add’l person* N/A Required AHCCCS ................
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