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Arizona FAA-1249A Verification of Disability (DES)

Arizona's Department of Economic Security uses this form when a Cash Assistance or Medical Assistance applicant or participant reports a condition that keeps them from working. A qualified professional states whether a temporary or permanent physical or mental condition or illness prevents gainful employment or participation in Jobs work preparation activities, and how long it is expected to last.

Who completes it

A qualified professional, such as a physician, physician assistant, nurse, nurse practitioner, licensed or certified psychologist or social worker, completes the Medical Information Completed by Qualified Professional section. The participant fills in their information and signs the authorization at the top.

Submitting and payment

How to submit it
The completed form goes back to the DES Family Assistance Administration office or caseworker handling the case.

Good to know

  • The central answers are whether the condition is temporary or permanent and how long it will last, which DES uses for Cash Assistance and Medical Assistance eligibility and Jobs participation.
  • The participant authorization at the top of the form is printed in both English and Spanish.
  • Large-print editions, FAA-1249A-LP and FAA-1249A-XLP, are listed for participants who need them.
  • Besides physicians and psychologists, the qualified professionals who can complete it include nurses, nurse practitioners, physician assistants and social workers.

Get the official form

Download the current version from the source each time; forms change without notice.

Verification of Disability

Official pagePDF

How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

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Frequently asked questions

Who can complete Arizona's FAA-1249A?

A qualified professional: a physician, physician assistant, nurse, nurse practitioner, licensed or certified psychologist, or social worker. They complete the medical information section, stating whether a physical or mental condition prevents gainful employment or Jobs activities and its expected duration, then sign.

Is the FAA-1249A available in Spanish?

The participant authorization on the three-page form is printed in both English and Spanish, so a Spanish-speaking participant can read what they are signing. DES also lists large-print editions, FAA-1249A-LP and FAA-1249A-XLP, in its Documents Center.

What happens to the FAA-1249A after it is completed?

It goes back to the DES Family Assistance Administration office or caseworker. DES uses the professional's statement on whether the condition prevents work and how long it will last when deciding Cash Assistance and Medical Assistance eligibility and Jobs participation.