S-PAC : Request for Help, Information & Support
To request assistance, please fill out the details below and submit the form to the S-PAC team.
Requester Name & Email
Type of Help Needed
Get Part B Paid Only
Medicaid Only (AHCCCS)
LIS help with Part D (medications)
Free Cell Phone or Tablet
Food Stamps
Food Box (Seniors Only)
Other (describe in Comments below)
Client Name(s)
Address
City, State Zipcode
Phone
Dates of Birth
Social Security #s (Last 4)
Monthly Income
Comments
Submit Request