DES-RRP STATEMENT OF UNDERSTANDING.PDF

Arizona Department of Economic Security - Arizona Refugee Resettlement Program (RRP)
Statement of Understanding
As an eligible Refugee Resettlement Program client in Arizona, you are being provided this document in the
language for which you have expressed proficiency. Should you identify that you are not literate in this
language, the document will be interpreted for you in the identified language of proficiency.
Refugee Medical Assistance
All refugees and other eligible beneficiaries arriving in Arizona have the right to apply for Refugee Medical
Assistance (RMA). RMA is a public benefit for those qualifying applicants denied eligibility for the Arizona
Health Care Cost Containment System (AHCCCS). RMA can pay for approved, allowable medical costs for a
maximum of eight months after arrival in the United States or grant of qualifying status. While RMA is only
available for a maximum of eight consecutive months, the coverage is comparable to that provided by
AHCCCS.
RMA also pays for the coordination of the Domestic Medical Examination for Newly Arrived Refugees (DME)
through its constituent program, Refugee Medical Screening (RMS).
The Resettlement Agency that sponsored you submits an RMA and/or RMS application on your behalf. The
Arizona Refugee Resettlement Program (RRP) determines eligibility for RMA and/or RMS. Should you be
approved for full RMA benefits, you will receive a Refugee Medical Assistance Card indicating the level of
your coverage.
You have the following rights and responsibilities as an RMA applicant:
• The right to have your RMA eligibility determined within 30 days from date of signed application.
• The right to a fair hearing should you be dissatisfied with the decision made regarding your eligibility.
• The right to receive the services for which you qualify pursuant to Federal and state regulations and
dependent upon the availability of services and fiscal limitations.
• The responsibility to report fully all circumstances affecting this application and to report to your case
manager within five days of any changes in your circumstances that will affect your eligibility.
• The responsibility to cooperate in current and subsequent agency efforts to establish your eligibility. You
agree to a full investigation of my eligibility, including inquiries to employers, doctors, and other business
and professional persons and review of other agency records.
You are currently receiving Refugee Resettlement Services from:
, (check desired option below) RRP to contact
the agency I am receiving Refugee Resettlement Services from to coordinate services.
O Authorize
O Do not authorize
1

I , (check desired option below) RRP to send my
contact, biographical information, eligibility documentation , and the contact/biographical/ eligibility
documentation information of any dependents listed in the applications section below, to the DME provider
operating in my County, through the Arizona Refugee Resettlement Program Online Data System (ARRPODS),
to facilitate the completion of my DME. You have the right to decline such transfers of your personal data being
made on your behalf by RRP, and screening referral may take place though other physical processes.
O Authorize
O Do not authorize
I , (check desired option below) RRP to send
my photograph and the photographs of any dependents listed in the applications section below, to the DME
provider operating in my County, through ARRPODS, to facilitate the completion of my DME. Photographs
shall only be used to aid the DME provider in client identification.
O Authorize
O Do not authorize
APPLICATIONS SUBMITTED
I (Witness/Case Manager) , have assessed the case
and confirm that I have submitted the proper RMA application into the ARRPODS on the applicant(s) behalf.
Name(s) of RMA Applicants
2

Refugee Resettlement Program Case Management and Employment Services
As part of your service delivery process, the Arizona Refugee Resettlement Program (RRP) or any RRP
contracted service provider you receive services from may make referrals to other service providers funded by
RRP to prove client eligibly status and facilitate your enrollment into services. RRP or its contracted providers
will make these referrals though the Arizona Refugee Resettlement Program Online Data System (ARRPODS).
Information shared includes contact, biographical information, eligibility documentation and a client
photograph. You have the right to decline such transfers of your personal data being made on your behalf by
RRP or its contracted service providers, and enrollment may take place though other physical processes.
I , (check desired option below) RRP, or any
RRP contracted provider whom I receive services from, to send my contact, biographical information, eligibility
documentation, and the contact/biographical/ eligibility documentation information of any dependents listed
below through the ARRPODS, to facilitate my enrollment into RRP funded case management and/or
employment services when I request services provided by another RRP contractor.
O Authorize
O Do not authorize
I , (check desired option below) RRP to send
my photograph and the photographs of any dependents listed below, to RRP funded case management and
employment services, through ARRPODS. Photographs shall only be used to aid RR_P funded providers in
client identification.
O Authorize
O Do not authorize
Name(s) of Dependents
3

Signatures
APPLICANT SIGNATURE DATE:
GUARDIAN/AUTHORIZED REPRESENTATIVE DATE:
RELATIONSHIP TO MINOR CLIENT
INTERPRETER SIGNATURE DATE:
(If interpretation was declined, please enter "N/A" above)
INTERPRETER DECLINED (Client to sign here) DATE: