Health Insurance Adults and APPLICATION Families · ManagedCareplan.Whenyoujoinaplan,youchooseonedoctor (PrimaryCareProviderorPCP)fromthatplantotakecareofyour regularneeds.Ifyouwanttokeepthedoctoryouhave,youneedto

for Children, Adults and

Families

Health Insurance APPLICATION

INSTRUCTIONS CONFIDENTIALITY STATEMENTAll of the information you provide on this application will remain confidential. The only people who will see this information are the Facilitated Enrollers and the State or local agencies and health plans who need to know this information in order to determine if you (the applicant) and your household members are eligible. The person helping you with this application cannot discuss the information with anyone, except a supervisor or the State or local agencies or health plans which need this information.

PURPOSE OF THIS APPLICATION Complete this application if you want health insurance to cover medical expenses. This application can be used to apply for Medicaid, the Family Planning Benefit Program, or for assistance paying your health insurance premiums. You can apply for yourself and/or immediate family members living with you.

IF YOU NEED HELP COMPLETING THIS APPLICATION DUE TO A DISABILITY, CALL YOUR LOCAL DEPARTMENT OF SOCIAL SERVICES. THEY WILL MAKE EVERY EFFORT TO PROVIDE REASONABLE ACCOMMODATIONS TO ADDRESS YOUR NEEDS.

PLEASE READ the entire application booklet before you begin to fill out the application. If you are applying ONLY for children or if you are a pregnant woman applying alone, you must complete only Sections A through G and Sections I and J. Other applicants must complete all sections.

If you are 65 years old or older, certified blind, certified disabled, or institutionalized and applying for coverage of nursing home care, you must also complete Supplement A. The supplement includes questions about your resources, such as money in the bank or property you own.

Whenever you see the words on the application refer to the “Documentation Needed When You Apply for Health Insurance” section for a listing of acceptable supporting documents.

HOW TO GET HELP When applying for public health insurance, you DO NOT need to visit your local department of social services or a Facilitated Enroller for an interview, but you MAY come in or contact a Facilitated Enroller for help filling out this application. You can get a list of Facilitated Enrollers where you got this application, or by calling 1-800-698-4543. ALL HELP IS FREE. (1-877-898-5849 TTY line for the hearing impaired)

SEND PROOF

SECTION A Applicant’s Information

Weneedtobeabletocontactthepeopleapplyingforhealthinsurance.Thehomeaddressiswherethepeopleapplyingforhealthinsurancelive.Themailingaddress,ifdifferent,iswhereyouwantustosendhealthinsurancecardsandnoticesaboutyourcase.Youcanalsotellusifyouwantsomeoneelsetogetinformationaboutyourcaseand/ortobeabletodiscussyourcase.

SECTION B Household Information

Pleaseincludeinformationforeveryonewholiveswithyoueveniftheyarenotapplyingforhealthinsurance.Itisimportantthatyoulisteveryonewholiveswithyousothatwecanmakeacorrecteligibilitydecision.Includemaidenname(legalnamebeforemarriage),ifthisappliestotheperson.AlsoincludeCity,StateandCountryofbirth.IfapersonwasbornoutsideoftheUnitedStates,justwritethecountryofbirth.Wealsoneed,foreachpersonapplying,his/hermother’sfullmaidenname(firstandlastname).Thisinformationmaybeusedtoobtainproofoftheapplicant’sbirthdateundercertaincircumstances.

Is this person pregnant?Ifso,whenisherbabyduetobeborn?Thisinformationhelpsusdeterminethesizeofyourfamily.Apregnantwomancountsastwopeople.

Relationship to the person on Line 1.ExplainhoweachpersonisrelatedtothepersonlistedonLine1(forexample,spouse,child,step-child,brother,sister,niece,nephew,etc.)

Public Health Coverage.IfyouoranyonewholiveswithyouisalreadyenrolledorwaspreviouslyenrolledinMedicaid,theFamilyPlanningBenefitProgram,oranyotherformofpublicassistancesuchasFoodStamps,weneedtoknow.Also,tellustheidentificationnumberontheNewYorkStateBenefitIdentificationCard.

Social Security Number.ASocialSecurityNumbershouldbeprovidedforallpersonsapplying,ifthepersonhasone.IfthepersondoesnothaveaSocialSecurityNumber,leavethisboxblank.

Citizenship and Immigration Status.Thisinformationisneededonlyforthosepeopleapplyingforhealthinsurance.Pregnantwomendonothavetocompletethisquestion.Tobeeligibleforhealthinsurance,otherpersonsage19andovermustbeU.S.citizensorbeinaneligibleimmigrationcategory.WeneedtoseeeitheroriginaldocumentationofU.S.citizenshipandidentity,orcopiesofthesedocuments.Pleasecontactyourlocaldepartmentofsocialservicesorcall1-800-698-4543tofindoutwhereyoucanbringthesedocuments.PleasenotethatifyouareonMedicare,orreceivingSocialSecurityDisabilitybutarenotyeteligibleforMedicare,itisnotnecessarytodocumentcitizenshiporidentity.

DOH-4220-I3/15Page2

PUBLIC CHARGE INFORMATION

TheUnitedStatesCitizenshipandImmigrationServices(USCIS)hasstatedthatenrollmentinMedicaid,ortheFamilyPlanningBenefitProgramCANNOTaffectaperson’sabilitytogetagreencard,becomeacitizen,sponsorafamilymember,ortravelinandoutofthecountry.ThisisnottrueifMedicaidpaysforlong-termcareinaplacesuchasanursinghomeorpsychiatrichospital.

The State will not report any information on this application to the USCIS.

Race/Ethnic Group. Thisinformationisoptionalanditwillhelpusmakesurethatallpeoplehaveaccesstotheprograms.Ifyoufilloutthisinformation,usethecodeshownontheapplicationthatbestdescribeseachperson’sraceorethnicbackground.Youmaypickmorethanone.

SECTION F Blind, Disabled, Chronically Ill or Nursing Home Care

SECTION C Household Income (Money Received)

Inthissection,listalltypesofincome(moneyreceived)andtheamountsreceivedbythepeopleyoulistedinSectionB.

Pleasetellushowmuchyoumakebeforetaxesaretakenout.

Ifthereisnomoneycomingintoyourhome,explainhowyouarepayingforyourlivingexpenses,suchasfoodandhousing.

Weneedtoknowifyouhavechangedjobsorifyouareastudent.

Wealsoneedtoknowifyoupayanotherpersonorplace,suchasadaycarecenter,totakecareofyourchildrenordisabledspouseorparentwhileyouareworkingorgoingtoschool.Ifyoudo,weneedtoknowhowmuchyoupay.Wemaybeabletodeductsomeoftheamountthatyoupayforthesecostsfromtheamountwecountasyourincome.

SECTION D Health Insurance

Itisimportanttotelluswhetheranyoneapplyingiscoveredorcouldbecoveredbysomeoneelse’shealthinsurance.Thisinformationmayaffecttheireligibilityforcoverage;forsomeapplicants,wecandeducttheamountthatyoupayforhealthinsurancefromtheamountwecountasyourincome;orwemaybeabletopaythecostofyourhealthinsurancepremiumifwedetermineitiscosteffective.Wemaybeabletohelppayforhealthinsurancepremiumsifyouhaveorcangetinsurancethroughyourjob.Wewillneedtogathermoreinformationabouttheinsuranceandwillmailaninsurancequestionnairetoyou.

SECTION E Housing Expenses

Writeinyourmonthlycostofhousing.Thisincludesyourrent,monthlymortgagepaymentorotherhousingpayment.Ifyouhaveamortgagepayment,includepropertytaxesintheamountyoutellus.Ifyoushareyourhousingexpensesoryourrentissubsidized,pleaseonlytellushowmuchYOUpaytowardyourrentormortgage.Ifyoupayforyourwater,tellushowmuchyoupayandhowoften.

DOH-4220-I3/15Page3

Thesequestionshelpusdeterminewhichprogramisbestforeachapplicant,andwhatservicesmaybeneeded.Apersonwithadisability,seriousillnessorhighmedicalbillsmaybeabletogetmorehealthservices.Youmayhaveadisabilityifyourdailyactivitiesarelimitedbecauseofanillnessorconditionthathaslastedorisexpectedtolastforatleast12months.Ifyouareblind,disabled,chronicallyillorneednursinghomecare,youwillneedtocompleteSupplementA.Ifneitheryounoranyoneapplyingisblind,disabled,chronicallyillorinanursinghome,gotoSectionG.

SECTION G Additional Health Questions

Ifyouhavepaidorunpaidmedicalbillsfromthepastthreemonths,Medicaidmaybeabletopayforthesecosts.Letusknowwhothesebillsareforandinwhichmonths.Includecopiesofthemedicalbillswiththisapplication.Note:Thisthree-monthperiodbeginswhenthelocaldepartmentofsocialservicesreceivesyourapplicationorwhenyoumeetwithaFacilitatedEnroller.Youwillneedtotelluswhatyourincomewasforanypastmonthsinwhichyouhavemedicalbillssothatwecanseeifyouareeligibleduringthattime.Wealsoaskaboutwhereyoulivedinthepastthreemonths,becausethismayaffectourabilitytopayforpastbills.Weaskaboutanypendinglawsuitsorhealthissuescausedbysomeoneelsesoweknowifsomeoneelseshouldpayforanyportionofyourmedicalcarecosts.

SECTION H Parent or Spouse Not Living in the Household or Deceased

If any applicants have an absent spouse or parent, you must complete this section so we can see if medical support is available to you or your child.

Pregnant women do not have to answer these questions until 60 days after the birth of their child.Allotherpeoplewhoareapplyingandareage21orovermustbewillingtoprovideinformationaboutaparentofanapplyingminororaspouselivingoutsidethehometobeeligibleforhealthinsurance,unlessthereisgoodcause.Anexampleof“goodcause”isfearofphysicaloremotionalharmtoyouorafamilymember.Question2referstothePARENT ofanyapplyingchildunderage21.Question3referstotheSPOUSEofanyoneapplying.

Iftheparentsarenotwillingtoprovidethisinformation,theapplyingchildmaystillbeeligibleforMedicaid.

SECTION I Health Plan Selection

What is a Health Plan?ApplyingforprogramsthroughAccessNYHealthCaremaymeanyougetyourhealthcarecoveragethroughaManagedCareplan.Whenyoujoinaplan,youchooseonedoctor(PrimaryCareProviderorPCP)fromthatplantotakecareofyourregularneeds.Ifyouwanttokeepthedoctoryouhave,youneedtopicktheplanthatworkswithyourdoctor.ManagedCarehealthplansfocusonpreventivecaresosmallproblemsdonotbecomebigones.Ifyouneedaspecialist,yourPCPwillreferyoutoone.

Who Must Choose a Health Plan?MOSTpeoplewhoareeligibleforMedicaidMUST chooseahealthplantogetmostoftheirMedicaidbenefits.Keepreadingtofindouthowtogetmoreinformationonthis.

How Do I Know What Health Plan to Choose and If I Can Enroll?ForMedicaid,ifyouwanttofindoutmoreabouthowmanagedcareplanswork,ifyouhavetojoin,andhowtochooseaplan,callMedicaid CHOICEat1-800-505-5678,orcallorvisityourlocaldepartmentofsocialservices.AskforaManagedCareEducationPacket.InformationabouthealthplansisalsoontheNYSDOHwebsiteatwww.nyhealth.gov.Youcanalsoenrollbyphone,bycalling1-800-505-5678.

NOTE: IfyouorafamilymemberarefoundeligibleforMedicaid,andareinacountythatdoesnotrequirepeopleonMedicaidtojoinahealthplan,youwillstillbeenrolledinthehealthplanyouchooseifitprovidesMedicaid,unlessyouchecktheboxontheapplicationthatsaysyoudon’twanttobeenrolled,ortellusyoudonotwanttobeenrolledbycallingorwritingtoyourlocaldepartmentofsocialservices.

SECTION J Signature

PleasereadtheparagraphinthissectioncarefullyandreadtheTerms, Rights and Responsibilitiessection.Youmustthensignanddatetheapplication.

DOH-4220-I3/15Page4

DOH-4220-I3/15Page5

DOCUMENTS NEEDED WHEN YOU APPLY FOR HEALTH INSURANCE Applicant Name Application Date

* Your enrollment cannot be completed until all NECESSARY items are received. If you need help getting any of these items, let us know.

YOU DO NOT NEED TO SHOW US ALL OF THESE DOCUMENTS. We only need documents that apply to you or others who are applying. We will need to see copies of

documents for identity and U.S. citizenship. Please contact your local department of social services or call 1-800-698-4543 to find out where you can bring identity

and U.S. citizenship documents. Many local departments of social services do not accept original documents by mail, so please check with them if you wish to mail

these documents. Copies of other documents can be mailed with your application.�

You need to provide proof of Identity, U.S. Citizenship and/or Immigration Status and Date of Birth.

YoucanprovideONEofthefollowingdocumentstoprovebothU.S.Citizenship,IdentityandyourDateofBirth:

☐U.S.passportbook/cardOR� ☐CertificateofNaturalization(DHSFormsN-550orN-570)OR� ☐CertificateofU.SCitizenship(DHSFormsN-560orN-561)OR� ☐NYSEnhancedDriver’sLicense(EDL). Whenoneoftheabovedocumentsisnotavailable,ONEdocumentfromEACHofthelistsbelowmaybeusedtoproveyourcitizenshipand/oridentity.

Thislistisnotall-inclusive.Ifyoudonothaveoneofthesedocuments,pleaserefertothe“HowtoGetHelp”sectionoftheinstructions.

Documents with * next to it also show date of birth

U.S. Citizenship

☐U.S.BirthCertificate* ☐CertificationofBirthissuedbyDepartmentofState

(FormsFS-545orDS-1350)*

☐ReportofBirthAbroad(FS-240) ☐U.S.NationalIDcard(FormI-197orI-179) ☐NativeAmericanTribalDocument* ☐Religious/SchoolRecords* ☐MilitaryrecordofserviceshowingU.S.placeofbirth ☐Finaladoptiondecree ☐EvidenceofqualifyingforU.S.citizenshipunderthe

ChildCitizenshipActof2000

Identity

☐StateDriver’slicenseorIDcardwithphoto* ☐IDcardissuedbyafederal,state,orlocalgovernmentagency ☐U.S.MilitarycardordraftrecordorU.SCoastGuardMerchantMarinerCard ☐SchoolIDcardwithaphoto(mayalsoshowdateofbirth) ☐CertificateofDegreeofIndianbloodorotherNativeAmerican/AlaskaNativetribal

documentwithphoto

☐VerifiedSchool,NurseryorDaycarerecords(forchildrenunder18)(mayalsoshowdateofbirth)

☐Clinic,DoctororHospitalrecords(forchildrenunder18)*

If you do not use one of the documents that show date of birth, you must also submit one of the following:

☐Marriagecertificate ☐NYSBenefitIdentificationCard

*Please return all necessary items by: or application may be denied.

DOH-4220-I3/15Page6

DOCUMENTS NEEDED WHEN YOU APPLY FOR HEALTH INSURANCE If you are not a U.S. Citizen

ThelistbelowcontainssomeofthemostcommonUnitedStatesCitizenshipandImmigrationServices(USCIS)formsusedtoshowyourimmigrationstatus.Thislistisnotall-inclusive.Ifyoudonothaveoneofthesedocuments,pleaserefertothe“HowtoGetHelp”sectionoftheinstructions.

WeneedtoseeONEofthefollowingdocumentstoprovebothImmigrationStatus,IdentityandyourDateofBirth:Documents with * next to it also show date of birth

Immigration Status/Identity Immigration Status, but require an additional Identity document ☐I-551PermanentResidentCard(“GreenCard”)* ☐ I-94Arrival/DepartureRecord* ☐EvidenceofContinuousU.S.Residencepriorto ☐I-688BorI-766EmploymentAuthorizationCard* ☐ USCISFormI-797NoticeofAction January1,1972

Home Address: This address must match the home address that you write in Section A of the application. The proof must be dated within 6 months of when you signed the application.

☐Lease/letter/rentreceiptwithyourhomeaddressfromlandlord ☐Driver’slicense(ifissuedinthepast6months) ☐UtilityBill(gas,electric,phone,cable,fuelorwater) ☐GovernmentIDcardwithaddress ☐Propertytaxrecordsormortgagestatement ☐Postmarkedenvelopeorpostcard(cannotuseifsenttoaP.O.Box)

PROOF OF CURRENT INCOME, OR INCOME YOU MIGHT GET IN THE FUTURE LIKE UNEMPLOYMENT BENEFITS OR A LAWSUIT: You must provide a letter, written statement, or copy of check or stubs, from the employer, person or agency providing the income. YOU DO NOT NEED TO SHOW US ALL OF THESE DOCUMENTS, only the ones that apply to you and the people living with you. One proof for each type of income you have is required. Provide the most recent proof of income before taxes and any other deductions. The proof must be dated, include the employee’s name and show gross income for the pay period. The proof must be for the last four weeks, whether you get paid weekly, bi-weekly, or monthly. It is important that these be current.

Wages and Salary Social Security Military Pay

☐Paycheckstubs ☐Awardletter/certificate ☐Awardletter ☐Letterfromemployeroncompanyletterhead,signedanddated ☐Annualbenefitstatement ☐Checkstub ☐CurrentsignedanddatedincometaxreturnandallSchedules** ☐CorrespondencefromSocialSecurityAdministration Income from Rent or Room/Board ☐Business/payrollrecords Workers’ Compensation ☐Letterfromroomer,boarder,tenant Self-Employment ☐Awardletter ☐Checkstub ☐CurrentsignedanddatedincometaxreturnandallSchedules** ☐Checkstub Interest/Dividends/Royalties ☐Recordsofearningsandexpenses/businessrecords Child Support/Alimony ☐Recentstatementfrombank,creditunionor

financialinstitutionUnemployment Benefits ☐Letterfrompersonprovidingsupport ☐Letterfrombroker☐Awardletter/certificate ☐Letterfromcourt ☐Letterfromagent☐MonthlybenefitstatementfromNYSDepartmentofLabor ☐Childsupport/alimonycheckstub ☐1099ortaxreturn(ifnootherdocumentation☐Printoutofrecipient’saccountinformationfromthe ☐CopyofNYEpicardwithprintout

isavailable)NYSDepartmentofLabor’swebsite(www.labor.state.ny.us) ☐Copyofchildsupportaccountinformationfrom

☐CopyofDirectPaymentCardwithprintout www.newyorkchildsupport.com�☐CorrespondencefromtheNYSDepartmentofLabor ☐Copyofbankstatementshowingdirectdeposit

Private Pensions/Annuities Veterans’ Benefits

☐Statementfrompension/annuity ☐Awardletter **Income tax returns for other than self-employed may be used for ☐Benefitcheckstub

applications prior to April 1 of the following year. ☐CorrespondencefromVeteransAffairs

http:www.newyorkchildsupport.comhttp:NYS�Department�of�Labor�s�website�(www.labor.state.ny.us

DOH-4220-I3/15Page7

DOCUMENTS NEEDED WHEN YOU APPLY FOR HEALTH INSURANCE If you pay to have care for your children or parents while you work, provide one of the following:

☐Writtenstatementfromdaycarecenterorotherchild/adultcareprovider ☐Canceledchecksorreceiptsthatshowyourpayments

Proof of health insurance, provide all that apply:

☐Proofofcurrentinsurance(Insurancepolicy,CertificateofInsuranceorInsuranceCard) ☐HealthInsuranceTerminationLetter ☐MedicareCard(Red,WhiteandBlueCard)

If you have medical bills in the last three months, provide all the following:

Fordeterminationofeligibilityformedicalexpensesfromthepastthreemonths:

☐Proofofincomeforthemonth(s)inwhichtheexpensewasincurred ☐Proofofresidency/homeaddressforthemonth(s)inwhichtheexpense

wasincurred

☐Medicalbillsforlastthreemonths,whetherornotyoupaidthem

Resources (only if you are over 65 or disabled and have no children under 21 living with you):

☐Bankaccountstatements:checking,savings,retirement(IRAandKeogh) ☐Stocks,bonds,certificatesstatements ☐CopyofLifeInsurancepolicy ☐Copyofburialtrustorfundburialplotdeedorfuneralagreement ☐Deedforrealestateotherthanresidence

Proof of Student Status for college students if employed:

☐Copyofschedule ☐Statementfromcollegeoruniversity ☐Othercorrespondencefromcollegeshowingstudentstatus

DOH-4220-I3/15Page8

ACCESS NY HEALTH CARE Medicaid Print clearly in blue or black ink. An incomplete application cannot be processed and will result in a delay of a decision on your application.

Legal First, Middle, Last Name

Date of Birth

Is this person

applying for health insurance?

Is this person

pregnant?

Is this person the parent of

an applying child?

What is the relationship

to the person

in Box 1?

If this person has or had public health coverage

in the p ast, check the box that applies.

Social Security Number (if you

have one)

*Race/ Ethnic Group

01

02

Legal First Name

Another Phone #

Street

Street Apt.#

Apt.#

City

City

Name

Street

City

State

State

State Zip Code

Zip Code

Zip Code

County

Apt.#

What Language Do You:

Middle Initial Legal Last Name

Primary Phone # Home CellWork Other

Home CellWork Other Speak? Read?

HOME ADDRESS ofthepersonsapplyingforhealthinsurance

Checkhereifhomeless

MAILING ADDRESS ofthepersonsapplyingforhealthinsuranceifdifferentfromabove.

OPTIONAL:IfthereisanotherpersonyouwouldliketoreceiveyourMedicaidnotices,pleaseprovidethisperson’scontactinformation.Iwantthiscontactpersonto:

Applyforand/orrenewMedicaidforme DiscussmyMedicaidapplicationorcase,ifneeded Getnoticesandcorrespondence

Phone #Check all that apply Home Cell Work Other

Yes No

Yes No

Male Female

Male Female

Yes No

Yes No

Yes No

WhatistheDueDate?

Yes No

WhatistheDueDate?

SELF Medicaid

FamilyHealthPlus

IDNumberfromBenefitCard/PlanCard,ifknown:

Medicaid

FamilyHealthPlus


U.S.Citizen Immigrant/non-citizen

Enterthedateyoureceivedyourimmigrationstatus______/______/______ MonthDayYear

Non-immigrant(Visaholder) Noneoftheabove




ThisPerson’sMother’sFullMaidenName

CityofBirth StateofBirth CountryofBirth


FullMaidenName(person’sbirthnamebeforetheyweremarried)


//

//


SEND PROOF

Please mark one box that indicates your current Citizenship or Immigration Status. Not needed for pregnant women

SEND PROOF

SEND PROOF

//

//

SECTION A Applicant’s Information Please tell us who you are and how to contact you.

If you live in the household, start with yourself. If you do not, start with any adults who live in the household. List the full legal names of the persons applying for or already receiving Medicaid and list the ID Number from their Benefit Card or health plan ID card. You must provide information for household members including: parents, step-parents, and spouses. You may provide information for other household members (for example, a dependent child under the age of 21). Listing other household members may allow us to give you a higher eligibility level. Pregnant women and children under 19 may be eligible for health insurance regardless of immigration status.

SECTION B Household Information

SEND PROOF Refer to the “Documents Needed When You Apply for Health Insurance” in the instructions on pages 1-3, “Documentation Checklist for Health Insurance”, for a list of documents that prove Identity, Citizenship or Immigration Status. *Race/Ethnic Group Codes (optional):A-Asian,B-BlackorAfrican-American,I-NativeAmericanorAlaskanNative,P-NativeHawaiianorotherPacificIslander,W-White,U-Unknown.PleasealsotellusifyouareHispanicorLatino-H

Legal First, Middle, Last Name

Date of Birth

Is this person

applying for health insurance?

Is this person

pregnant?

Is this person the parent of

an applying child?

What is the relationship

to the person

in Box 1?

If this person has or had public health coverage

in the p ast, check the box that applies.

Social Security Number (if you

have one)

*Race/ Ethnic Group

03

04

05

06

07

Yes No

Male Female

Yes No

Medicaid

FamilyHealthPlus




Non-immigrant(Visaholder) NoneoftheaboveThisPerson’sMother’sFullMaidenName



Yes No

WhatistheDueDate?

//


Yes No

Male Female

Yes No

Medicaid

FamilyHealthPlus







//

//


Yes No

Male Female

Yes No

Medicaid

FamilyHealthPlus







//


Yes No

Male Female

Yes No

Medicaid

FamilyHealthPlus







//


Yes No

Male Female

Yes No

Medicaid

FamilyHealthPlus







//

Isanyoneinyourhouseholdaveteran? Yes NoIfyes,name:

SEND PROOF

Please mark one box that indicates your current Citizenship or Immigration Status. Not needed for pregnant womenSEND PROOF

Yes No

WhatistheDueDate?

//

Yes No

WhatistheDueDate?

//

Yes No

WhatistheDueDate?

//

Yes No

WhatistheDueDate?

//

DOH-4220-I3/15Page9

SECTION B Household Information (Continued from previous page)

SEND PROOF Refer to the “Documents Needed When You Apply for Health Insurance” in the instructions on pages 1-3, “Documentation Checklist for Health Insurance”, for a list of documents that prove Identity, Citizenship or Immigration Status.

*Race/Ethnic Group Codes (optional):A-Asian,B-BlackorAfrican-American,I-NativeAmericanorAlaskanNative,P-NativeHawaiianorotherPacificIslander,W-White,U-Unknown.PleasealsotellusifyouareHispanicorLatino-H

DOH-4220-I3/15Page10

SECTION C Household Income Write the types of money and the amount received by everyone listed in Section B and SEND PROOF

Earnings from Work:Includeswages,salaries,commissions,tips,overtime,self-employment.Ifyouareself-employedcheckhere: Checkhereifnoearningsfromwork:Name of Person Type of Income/Employer Name How Much? (before taxes) How Often? (weekly, monthly)

Unearned Income:IncludesSocialSecurityBenefits,disabilitypayments,unemploymentpayments,interestanddividends,veterans’benefits,Workers’Compensation,childsupportpayments/alimony,rentalincome,pension,annuitiesandtrustincome.Checkhereifnounearnedincome:

Name of Person Type of Income/Source How Much? (before taxes) How Often? (weekly, monthly)

Contributions: Moneyfromrelativesorfriends,roomersorboarders(includemoneythatanyonegivesyoueachmonthtohelpmeetlivingexpenses).Checkhereifnocontributions: Name of Person Type of Income/Source How Much? (before taxes) How Often? (weekly, monthly)

Other: Temporary(cash)Assistance,SupplementalSecurityIncome(SSI)payments,studentgrants,orloans.Checkhereifnone: Name of Person Type of Income/Source How Much? (before taxes) How Often? (weekly, monthly)

1.DoyouoranyapplyingadultinSectionBhavenoincome? No Yes Who?_____________________________________________________________

2.Ifthereisnoincomelistedabove,pleaseexplainhowyouareliving:(For example: living with friend or relative)

3.Haveyouoranyonewhoisapplyingchangedjobsorstoppedworkinginthelast3months? No Yes

Ifyes:Yourlastjobwas:Date______/______/______ NameofEmployer:

4.Areyouoranyonewhoisapplyingastudentinavocational,undergraduate,orgraduateprogram? No Yes

Ifyes: FullTime PartTime Undergraduate Graduate Student’sName:

5.Doyouhavetopayforchildcare(orforcareofadisabledadult)inordertoworkorgotoschool? No Yes

Child’s/adult’sname: Howmuch?$ HowOften?(weekly,everytwoweeks,monthly)



6.IfyouarenoteligibleforMedicaidcoverage,youmaystillbeeligiblefortheFamilyPlanningBenefitProgram.AreyouinterestedinreceivingcoverageforFamilyPlanningServicesonly? No Yes

You and your family may still be eligible even if you have other health insurance.


SECTION D Health Insurance

1.DoesanyonewhoisapplyinghaveMedicare? No YesIf yes, include a copy of your card (red, white and blue card), for each Medicare beneficiary.

Complete the rest of this application and complete Supplement A. SEND PROOF

2.Doesanyonewhoisapplyingalreadyhaveothercommercialhealthinsurance,includinglongtermcareinsurance? No Yes If yes, you must send a copy of the front and back of the insurance card with this application. SEND PROOF

NameofInsured(primary)____________________________________ PersonsCovered_________________________________ CostofPolicy____________

Enddateofcoverage,ifendingsoon______/_______/_______ MonthDayYear

Note:IfyouareapplyingfortheMedicareSavingsProgramonly(MSP),gotoSectionG.YoudoNOTneedtocompleteSupplementA.

3.Doesyourcurrentjobofferhealthinsurance?We may be able to help pay for it. No YesIfyes,a“RequestforInformationEmployerSponsoredHealthInsurance”formwillbesenttoyou.

SECTION E Housing Expenses

1.Monthlyhousingpaymentsuch as rent or mortgage, including property taxes(justyourshare).$___________________

2.Ifyoupayforwaterseparatelyhowmuchdoyoupay?$________________SEND PROOF Howoftendoyoupay? everymonth 2timesayear quarterly(4timesayear) onceayear

3.Doyoureceivefreehousingaspartofyourpay? No Yes

If no one applying is Blind, Disabled, Chronically Ill or in a Nursing Home please go to Section G.STOP

SECTION F Blind, Disabled, Chronically Ill or Nursing Home Care These questions help us determine which program is best for the applicants.

1.Areyou,oranyonewholiveswithyou,andisapplying,inaresidentialtreatmentfacilityorreceivingnursing home careinahospital,nursinghomeorothermedicalinstitution? No YesIfyes,finishcompletingthisapplicationANDcompleteSupplementA.

2.Areyouoranyonewholiveswithyoublind,disabledorchronicallyill? No Yes Ifyes,finishcompletingthisapplicationANDcompleteSupplementA.

Note:IfyouareapplyingfortheMedicareSavingsProgramonly(MSP),gotoSectionG.YoudonotneedtocompleteSupplementA.


SECTION G Additional Health Questions

1.Doesanyoneapplyinghavepaidorunpaidmedicalorprescriptionbillsforthismonthorthethreemonthsbeforethismonth?Medicaidmaybeabletopaythesebillsorreimburseyou.

No Yes Ifyes: Name:___________________________________________________ Inwhichmonth(s)ofthepreviousthreemonthsdoyouhavemedicalbills?_________________________________

of income for any month in the three-month period for which you have bills. If you have paid medical bills for which you are seeking reimbursement, you must send copies and proof of payment.SEND PROOF

2.Doyou,oranyoneapplying,haveanyunpaidmedicalorprescriptionbillsolderthanthepreviousthreemonths? No Yes

3.Haveyou,oranyonewholiveswithyouandisapplying,movedintothiscountyfromanotherstateorNewYorkStatecountywithinthepastthreemonths? No Yes

Ifyes,who?_________________________________________________________ Whichstate?________________________________________ Whic hcounty?__________________________________

4.Doesanyonewhoisapplyinghaveapendinglawsuitduetoaninjury? No Yes Ifyes,who:__________________________________________________________

5. DoesanyoneapplyinghaveaWorkers’Compensationcaseoraninjury,illness,ordisabilitythatwascausedbysomeoneelse(thatcouldbecoveredbyinsurance)? No Yes

Ifyes,who?_______________________________________________________________________________________________

SECTION H Parent or Spouse Not Living in the Household or Deceased

Families who are applying for their children and pregnant women are NOT required to fill out this section. All other people who are applying and are age 21 or over must be willing to provide information about a parent of an applying minor or a spouse living outside the home to be eligible for health insurance, unless there is good cause. Children may still be eligible even if a parent is not willing to provide this information. If you fear physical or emotional harm as a result of providing information about a parent or spouse not living in the home, you may be excused from providing this information. This is called Good Cause. You may be asked to show that you have a good reason for your fears.

1.Isthespouseorparentofanyoneapplyingdeceased? No Yes

Ifyes,nameofapplicantwithdeceasedparentorspouse:__________________________________________ (Ifspouseorparentisdeceasedgotoquestion3.)

2.Doesaparentofanyapplyingchildliveoutsidethehome?(Ifno,skiptoquestion3) No Yes

Ifyoufearphysicaloremotionalharmifyouprovideinformationaboutaparentwhodoesnotliveinthehome,checkthisbox

Child’s Name: Name of parent living outside the home

DateofBirth(ifknown):______/______/______

Current or last known address:

Street:City/State:

SSN(ifknown):

Child’s Name: Name of parent living outside the home

DateofBirth(ifknown):______/______/______


Street:City/State:

SSN(ifknown):

3.Isanyoneapplyingstillmarriedtosomeonewholivesoutsidethehome? No Yes Ifyes,nameofpersonapplyingwhoisstillmarried:____________________________________________

Ifyoufearphysicaloremotionalharmifyouprovideinformationaboutaspousewhodoesnotliveinthehome,checkthisbox

Legal name of spouse living outside of the home: Date of Birth (if known):

______/______/______


Street:City/State:

SSN(ifknown):


SECTION I Health Plan Selection

If you are in receipt of Medicare, skip this section.STOP

IMPORTANT: MostpeoplewithMedicaidmustchooseahealthplan;ifyoudon’tchooseahealthplanyoumaybeautomaticallyenrolledinoneunlessitisdeterminedyouareexempt. Ifyouneedinformationaboutwhatplansareavailableinyourcounty,whatplansyourdoctorisinandifyouhavetojoin,pleasecallNew York Medicaid CHOICEat1-800-505-5678.YoucanalsocallorvisityourlocalDepartmentofSocialServices.Ifyoualreadyknowwhatplanyouwant,usethissectionforyourplanchoice.

NOTE:IfyouorfamilymembersarefoundeligibleforMedicaid,youwillbeenrolledinthehealthplanyouchooseifitprovidesMedicaid.IfyouliveinacountythatdoesnotrequirepeopleonMedicaidtojoinahealthplan,youcantellusyoudonotwanttobeinahealthplanbycallingorwritingtoyourlocalDepartmentofSocialServicesorbycheckingthisbox

Legal Last Name Legal First Name Date of Birth Social Security # Name of Health Plan You are Enrolling in

Preferred Doctor or Health Center (optional) Check Box if Your Current Provider OB/GYN (optional)

SECTION J Signature

IagreetohavetheinformationonthisapplicationandontheannualrenewalsharedonlyamongMedicaid,thehealthplansindicatedinSectionI,thelocalsocialservicesdistrict,andthefacilitatedenrollmentorganizationprovidingtheapplicationassistance.Ialsoconsenttosharingthisinformationwithanyschool-basedhealthcenterthatprovidesservicestotheapplicant(s).IunderstandthisinformationisbeingsharedforthepurposeofdeterminingtheeligibilityofthoseindividualsapplyingforMedicaid,ortoevaluatethesuccessoftheseprograms.Eachapplyingadultmustsignthisapplicationinthespacebelow.I have read and understand the Terms, Rights and Responsibilities included in this application booklet on the next page.IcertifyunderpenaltyofperjurythateverythingonthisapplicationisthetruthasbestIknow.

Date Signature of adult applicant or authorized representative for the applicant

Date Signature of adult applicant or authorized representative for the applicant

TERMS, RIGHTS AND RESPONSIBILITIES

Bycompletingandsigningthisapplication,IamapplyingforMedicaid.Iunderstandthatthisapplication,noticesandothersupportinginformationwillbesenttotheprogram(s)forwhichIwanttoapply.Iagreetothereleaseofpersonalandfinancialinformationfromthisapplicationandanyotherinformationneededtodetermineeligibilityfortheseprograms.IunderstandthatImaybeaskedformoreinformation.Iagreetoimmediatelyreportanychangestotheinformationonthisapplication.

• IunderstandthatImustprovidetheinformationneededtoprovemyeligibilityforeachprogram.IfIhavebeenunabletogettheinformationforMedicaid,Iwilltellthesocialservicesdistrict.Thesocialservicesdistrictmaybeabletohelpingettingtheinformation.

• IfIamapplyingataplaceotherthanalocaldepartmentofsocialservices,andmychildrenarenotfoundeligibleforMedicaidusingthisapplication,IcancontactthelocaldepartmentofsocialservicestoseeifmychildrenareeligibleforMedicaidonsomeotherbasis.

• IunderstandthatworkersfromtheprogramsforwhichfamilymembersorIhaveappliedmaychecktheinformationgivenbymeforthisapplication.Theagenciesthatruntheseprogramswillkeepthisinformationconfidentialaccordingto42U.S.C.1396a(a)(7)and42CFR431.300-431.307,andanyfederalandstatelawsandregulations.

• IunderstandthatMedicaid,willnotpaymedicalexpensesthatinsuranceoranotherpersonissupposedtopay,andthatifIamapplyingforMedicaid,Iamgivingtotheagencyallofmyrightstopursueandreceivemedicalsupportfromaspouseorparentsofpersonsunder21yearsoldandmyrighttopursueandreceivethirdpartypaymentsfortheentiretimeIaminreceiptofbenefits.

• IwillfileanyclaimsforhealthoraccidentinsurancebenefitsoranyotherresourcestowhichIamentitled.IunderstandthatIhavetherighttoclaimgoodcausenottocooperateinusinghealthinsuranceifitsusecouldcauseharmtomyhealthorsafetyortothehealthandsafetyofsomeoneIamlegallyresponsiblefor.

• IunderstandthatmyeligibilityforMedicaidwillnotbeaffectedbymyrace,color,ornationalorigin.Ialsounderstandthatdependingontherequirementsoftheprogram,myage,sex,disabilityorcitizenshipstatusmaybeafactorinwhetherornotIameligible.

• IunderstandthatifmychildisonMedicaid,heorshecangetcomprehensiveprimaryandpreventivecare,includingallnecessarytreatmentthroughtheChild/TeenHealthProgram.Icangetmoreinformationonthisprogramfromthelocaldepartmentofsocialservices.

• Iunderstandthatanyonewhoknowinglyliesorhidesthetruthinordertoreceiveservicesundertheseprogramsiscommittingacrimeandsubjecttofederalandstatepenaltiesandmayhavetorepaytheamountofbenefitsreceivedandpaycivilpenalties.TheNewYorkStateDepartmentofTaxandFinancehastherighttoreviewincomeinformationonthisform.

SOCIAL SECURITY NUMBER

SSNsarerequiredforallapplicants,unlessthepersonispregnantoranon-qualifiedalien.SSNsarenotrequiredformembersofmyhouseholdwhoarenotapplyingforbenefitsunlessthepersonismyspouseandmyeligibilitydependsontheamountofresourcesownedbymyspouse.IunderstandthatthisisrequiredbyFederalLawat42U.S.C.1320b-7(a)andbyMedicaidregulationsat42CFR435.910.SSNsareusedinmanyways,bothwithindepartmentofsocialservices(DSS)andbetweentheDSSandfederal,state,andlocalagencies,bothinNewYorkandotherjurisdictions.SomeusesofSSNsare:tocheckidentity,toidentifyandverifyearnedandunearnedincome,toseeifnon-custodialparentscangethealthinsurancecoverageforapplicants,toseeifapplicantscangetmedicalsupport,toseeifapplicantscangetmoneyorotherhelp,andtoverifyresourceswithfinancialinstitutionsforapplicantsandtheirnon-applyingspouse.SSNsmayalsobeusedforidentificationoftherecipientwithinandbetweencentralgovernmentalMedicaidagenciestoinsureproperservicesaremadeavailabletotherecipient.Also,ifIapplyforotherprogramsinthisjointapplication,thoseprogramswillhaveaccesstomySSNandcoulduseitintheadministrationoftheprogram.

FOR MEDICAID APPLICANTS ONLY

• ReleaseofEducationalRecordsIgivepermissiontothelocaldepartmentofsocialservicesandNewYorkStatetoobtainanyinformationregardingtheeducationalrecordsofmychild(ren),hereinnamed,necessaryforclaimingMedicaidreimbursementsforhealth-relatededucationalservices,andtoprovidetheappropriatefederalgovernmentagencyaccesstothisinformationforthesolepurposeofaudit.

• EarlyInterventionProgramIfmychildisevaluatedfororparticipatesintheNewYorkStateEarlyInterventionProgram,IgivepermissiontothelocaldepartmentofsocialservicesandNewYorkStatetosharemychild’sMedicaideligibilityinformationwithmycountyEarlyInterventionProgramforthepurposeofbillingMedicaid.

• ReimbursementofMedicalExpensesIunderstandthatIhavearightaspartofmyMedicaidapplication,orlater,torequestreimbursementofexpensesIpaidforcoveredmedicalcare,servicesandsuppliesreceivedduringthethreemonthperiodpriortothemonthofmyapplication.Afterthedateofmyapplication,reimbursementofcoveredmedicalcare,servicesandsupplieswillonlybeavailableifobtainedfromMedicaidenrolledproviders.

MEDICAID MANAGED CARE

IhavereadhowtofindoutwhethermycountyrequiresMedicaidenrolleestojoinahealthplan,andhowtofindoutwhathealthplansareavailabletomeinMedicaidmanagedcare.I/wealsounderstandthatifI/wearefoundeligibleforMedicaidandI/weareinacountythatrequiresMedicaidenrolleestobeinamanagedcarehealthplan,I/wewillbeenrolledinthehealthplanI/wechoseunlessthathealthplandoesnotparticipateinMedicaidmanagedcare.


TERMS, RIGHTS AND RESPONSIBILITIES

IfI/weareinacountythatdoesnotrequireenrolleestobeinaMedicaidmanagedcarehealthplan,I/wewillstillbeenrolledinthehealthplanI/wechoseunlessI/wenotifymylocalsocialservicesdepartmentinwriting,orI/wechecktheboxinSectionI,thatI/wedonotwanttobeinthatplan.

IhavereadhowtofindouttherightsandbenefitsthatIwillhaveasamemberofamanagedcarehealthplanandthebenefitlimitationsofmanagedcaremembership.IunderstandthatinMedicaidmanagedcare,ImustchooseaPrimaryCareProvider(PCP)andthatIwillhaveachoicefromatleastthreePCPsinmyhealthplan.IunderstandthatonceIenrollinahealthplan,IwillhavetousemyPCPandotherprovidersinmyhealthplanexceptinafewspecialcircumstances.

IunderstandthatifachildisborntomewhileIamamemberofaMedicaidmanagedcarehealthplan,mychildwillbeenrolledinthesamehealthplanthatIamin.IunderstandthatifachildisborntomewhileIamamemberofaMedicaidmanagedcare,mychildwillbeenrolledinthesamehealthplanthatIamin.

• ReleaseofMedicalInformationIconsenttothereleaseofanymedicalinformationaboutmeandanymembersofmyfamilyforwhomIcangiveconsent:

•BymyPCP,anyotherhealthcareproviderortheNewYorkStateDepartmentofHealth(NYSDOH)tomyhealthplanandanyhealthcareprovidersinvolvedincaringformeormyfamily,asreasonablynecessaryformyhealthplanormyproviderstocarryouttreatment,payment,orhealthcareoperations.Thismayincludepharmacyandothermedicalclaimsinformationneededtohelpmanagemycare;

•BymyhealthplanandanyhealthcareproviderstoNYSDOHandotherauthorizedfederal,state,andlocalagenciesforpurposesofadministrationoftheMedicaidprograms;and

•Bymyhealthplantootherpersonsororganizations,asreasonablynecessaryformyhealthplantocarryouttreatment,payment,orhealthcareoperations.

Ialsoagreethattheinformationreleasedfortreatment,paymentandhealthcareoperationsmayincludeHIV,mentalhealthoralcoholandsubstanceabuseinformationaboutmeandmembersofmyfamilytotheextentpermittedbylaw,untilIrevokethisconsent.

IfmorethanoneadultinthefamilyisjoiningaMedicaidhealthplan,thesignatureofeachadultapplyingisnecessaryforconsenttoreleaseinformation.

FOR OFFICE USE ONLY

To be completed by the person assisting with the application

SignatureofPersonWhoObtainedEligibilityInformation:

X

To be used by the local Social Services District

EligibilityDeterminedBy: Date:

EmployedBy:(checkone)

HealthPlan SocialServicesDistrict

EmployerName:

ProviderAgency QualifiedEntities

Date:

CenterOffice: ApplicationDate:

EligibilityApprovedBy:

UnitID: WorkerID:

CaseName: District: CaseType: Case#:

EffectiveDate: MADispositionReasonCode:

DenialCode Withdrawal

Proxy:

Yes

No

Registry#: Ver:


doh-4220 1doh-4220 2doh-4220 3doh-4220 4doh-4220 5doh-4220 6doh-4220 7doh-4220 8doh-4220 9doh-4220 10doh-4220 11doh-4220 12doh-4220 13doh-4220 14doh-4220 15

Applicant Name: Application Date: USpassportbookcardOR: OffCertificateofNaturalizationDHSFormsN550orN570OR: OffCertificateofUSCitizenshipDHSFormsN560orN561OR: OffNYSEnhancedDriversLicenseEDL: OffUSBirthCertificate: OffCertificationofBirthissuedbyDepartmentofState: OffReportofBirthAbroadFS240: OffUSNationalIDcardFormI197orI179: OffNativeAmericanTribalDocument: OffReligiousSchoolRecords: OffMilitaryrecordofserviceshowingUSplaceofbirth: OffFinaladoptiondecree: OffEvidenceofqualifyingforUScitizenshipunderthe: OffStateDriverslicenseorIDcardwithphoto: OffIDcardissuedbyafederalstateorlocalgovernmentagency: OffUSMilitarycardordraftrecordorUSCoastGuardMerchantMarinerCard: OffSchoolIDcardwithaphotomayalsoshowdateofbirth: OffCertificateofDegreeofIndianbloodorotherNativeAmericanAlaskaNativetribal: OffVerifiedSchoolNurseryorDaycarerecordsforchildrenunder18: OffClinicDoctororHospitalrecordsforchildrenunder18: OffMarriagecertificate: OffNYSBenefitIdentificationCard: OffI551PermanentResidentCardGreenCard: OffI688BorI766EmploymentAuthorizationCard: OffI94ArrivalDepartureRecord: OffEvidenceofContinuousUSResidencepriorto: OffUSCISFormI797NoticeofAction: OffLeaseletterrentreceiptwithyourhomeaddressfromlandlord: OffDriverslicenseifissuedinthepast6months: OffUtilityBillgaselectricphonecablefuelorwater: OffGovernmentIDcardwithaddress: OffPropertytaxrecordsormortgagestatement: OffPostmarkedenvelopeorpostcardcannotuseifsenttoaPOBox: OffPaycheckstubs: OffAwardletter: OffAwardlettercertificate: OffAnnualbenefitstatement: OffLetterfromemployeroncompanyletterheadsignedanddated: OffCheckstub: OffCorrespondencefromSocialSecurityAdministration: OffCurrentsignedanddatedincometaxreturnandallSchedules: OffBusinesspayrollrecords: OffLetterfromroomerboardertenant: OffAwardletter_2: OffCheckstub_3: OffCurrentsignedanddatedincometaxreturnandallSchedules_2: OffCheckstub_2: OffRecordsofearningsandexpensesbusinessrecords: OffRecentstatementfrombankcreditunionor: OffLetterfrompersonprovidingsupport: OffAwardlettercertificate_2: OffLetterfrombroker: OffLetterfromcourt: OffMonthlybenefitstatementfromNYSDepartmentofLabor: OffLetterfromagent: OffChildsupportalimonycheckstub: Off1099ortaxreturnifnootherdocumentation: OffPrintoutofrecipientsaccountinformationfromthe: OffCopyof: OffCopyofchildsupportaccountinformationfrom: OffCopyofDirectPaymentCardwithprintout: OffCopyofbankstatementshowingdirectdeposit: OffCorrespondencefromtheNYSDepartmentofLabor: OffStatementfrompensionannuity: OffAwardletter_3: OffBenefitcheckstub: OffCorrespondencefromVeteransAffairs: OffWrittenstatementfromdaycarecenterorotherchildadultcareprovider: OffCanceledchecksorreceiptsthatshowyourpayments: OffProofofcurrentinsuranceInsurancepolicyCertificateofInsuranceorInsuranceCard: OffHealthInsuranceTerminationLetter: OffMedicareCardRedWhiteandBlueCard: OffProofofincomeforthemonthsinwhichtheexpensewasincurred: OffProofofresidencyhomeaddressforthemonthsinwhichtheexpense: OffMedicalbillsforlastthreemonthswhetherornotyoupaidthem: OffBankaccountstatementscheckingsavingsretirementIRAandKeogh: OffStocksbondscertificatesstatements: OffCopyofLifeInsurancepolicy: OffCopyofburialtrustorfundburialplotdeedorfuneralagreement: OffDeedforrealestateotherthanresidence: OffCopyofschedule: OffStatementfromcollegeoruniversity: OffOthercorrespondencefromcollegeshowingstudentstatus: OffLegal First Name: Middle Initial: Legal Last Name: Primaryphonepg8: Home1: OffWork1: OffCell5: OffOther1: OffAnotherPhoneph8: Home2: OffWork2: OffCell9: OffOther2: OffSpeak: Read: Check here if homeless3: OffStreet: City: State: Apt: Zip Code: County: Street_2: City_2: Apt_2: State_2: Zip Code_2: ApplyforandorrenewMedicaidforme: OffDiscussmyMedicaidapplicationorcaseifneeded: OffGetnoticesandcorrespondence: OffName: Street_3: Apt_3: City_3: State_3: Zip Code_3: Home: OffCell: OffWork: OffOther: OffFullMaidenNamepersonsbirthnamebeforetheyweremarried: City of Birthpg8: StateofBirthpg8: Country of Birth pg8: CityofBirth StateofBirth CountryofBirth: Date of Month pg8 1: Date of daypg8 1: Date of year pg8 1: Male pg81: OffFemalepg81: OffYespg81: OffNopg81: OffYespg82: OffNopg82: OffDate of Month pg8 2: Date of daypg8 2: Date of year pg8 2: Yespg83: OffNopg83: OffMedicaid 1: OffFamily Health Plus 1: OffSocial Security Number if you have oneMedicaid FamilyHealthPlus IDNumberfrom BenefitCardPlanCard ifknown1: U: S: Citizen#1: Off Citizen#12: Off Citizen#1203: Off Citizen#120304: Off Citizen#12030405: Off Citizen#1203040506: Off Citizen#120304050607: Off

Immigrant/non-citizen1: OffMonth: undefined: undefined_2: Non-immigrant (Visa holder)1: OffNone of the above1: OffRace Ethnic GroupUSCitizen Immigrantnoncitizen Enterthedateyoureceived yourimmigrationstatus Month Day Year NonimmigrantVisaholder Noneoftheabove: FullMaidenNamepersonsbirthnamebeforetheyweremarried2: City of Birthpg82: StateofBirthpg82: Country of Birth pg82: CityofBirth StateofBirth CountryofBirth_2: Date of Month pg8 3: Date of daypg8 3: Date of year pg8 3: Male pg812: OffFemalepg812: OffYespg812: OffNopg812: OffYespg22: OffNopg822: OffDate of Month pg8 4: Date of daypg8 4: Date of year pg8 4: Yespg832: OffNopg832: OffSELFYes No: Medicaid 12: OffFamily Health Plus 12: OffSocial Security Number if you have oneMedicaid FamilyHealthPlus IDNumberfrom BenefitCardPlanCard ifknown_20: Immigrant/non-citizen12: OffMonthpg82: undefinedpg82: undefined_2pg8 2: Non-immigrant (Visa holder)12: OffNone of the above12: OffRace Ethnic GroupUSCitizen Immigrantnoncitizen Enterthedateyoureceived yourimmigrationstatus Month Day Year NonimmigrantVisaholder Noneoftheabove_2: ID number from benefit 1: ID number from benefit 2: FullMaidenNamepersonsbirthnamebeforetheyweremarried03: City of Birthpg8203: StateofBirthpg8203: Country of Birth pg8203: CityofBirth StateofBirth CountryofBirth_203: Date of Month pg8 5: Date of daypg8 5: Date of year pg8 5: Male pg81203: OffFemalepg81203: OffYespg81203: OffNopg81203: OffYespg82203: OffNopg82203: OffDate of Month pg8 6: Date of daypg8 6: Date of year pg8 6: Yespg83203: OffNopg83203: OffSELFYes No03: Medicaid 1203: OffFamily Health Plus 1203: OffSocial Security Number if you have oneMedicaid FamilyHealthPlus IDNumberfrom BenefitCardPlanCard ifknown_2: Immigrant/non-citizen1203: OffMonthpg8203: undefinedpg8203: undefined_2pg8 203: Non-immigrant (Visa holder)1203: OffNone of the above1203: OffRace Ethnic GroupUSCitizen Immigrantnoncitizen Enterthedateyoureceived yourimmigrationstatus Month Day Year NonimmigrantVisaholder Noneoftheabove_203: FullMaidenNamepersonsbirthnamebeforetheyweremarried0304: City of Birthpg820304: StateofBirthpg820304: Country of Birth pg820304: CityofBirth StateofBirth CountryofBirth_20304: Date of Month pg8 7: Date of daypg8 7: Date of year pg8 7: Male pg8120304: OffFemalepg8120304: OffYespg8120304: OffNopg8120304: OffYespg8220304: OffNopg8220304: OffDate of Month pg8 8: Date of daypg8 8: Date of year pg8 8: Yespg8320304: OffNopg8320304: OffSELFYes No0304: Medicaid 120304: OffFamily Health Plus 120304: OffMonthpg820304: Immigrant/non-citizen120304: Offundefinedpg820304: Social Security Number if you have oneMedicaid FamilyHealthPlus IDNumberfrom BenefitCardPlanCard ifknown_204: undefined_2pg8 20304: Non-immigrant (Visa holder)120304: OffNone of the above120304: OffRace Ethnic GroupUSCitizen Immigrantnoncitizen Enterthedateyoureceived yourimmigrationstatus Month Day Year NonimmigrantVisaholder Noneoftheabove_20304: FullMaidenNamepersonsbirthnamebeforetheyweremarried0305: Date of Month pg8 9: Date of daypg8 9: Date of year pg8 9: Yespg812030405: OffYespg822030405: OffYespg832030405: OffNopg812030405: OffMedicaid 12030405: OffImmigrant/non-citizen12030405: OffNopg822030405: OffMale pg812030405: OffNopg832030405: OffFamily Health Plus 12030405: OffStateofBirthpg82030405: undefinedpg82030405: undefined_2pg8 2030405: CityofBirth StateofBirth CountryofBirth_2030405: City of Birthpg82030405: Femalepg812030405: OffCountry of Birth pg82030405: Monthpg82030405: Date of year pg8 10: Date of daypg8 10: Date of Month pg8 10: Social Security Number if you have oneMedicaid FamilyHealthPlus IDNumberfrom BenefitCardPlanCard ifknown_20405: SELFYes No030405: Non-immigrant (Visa holder12030405: OffNone of the above12030405: OffRace Ethnic GroupUSCitizen Immigrantnoncitizen Enterthedateyoureceived yourimmigrationstatus Month Day Year NonimmigrantVisaholder Noneoftheabove_2030405: Date of Month pg8 11: Date of daypg8 11: Date of year pg8 11: City of Birthpg8203040506: FullMaidenNamepersonsbirthnamebeforetheyweremarried0306: StateofBirthpg8203040506: CityofBirth StateofBirth CountryofBirth_203040506: Yespg82203040506: OffYespg83203040506: OffImmigrant/non-citizen1203040506: OffMedicaid 1203040506: OffFemalepg81203040506: OffNopg82203040506: OffNopg83203040506: OffNopg220304050607: OffFamily Health Plus 1203040506: OffYespg81203040506: OffNopg81203040506: OffSocial Security Number if you have oneMedicaid FamilyHealthPlus IDNumberfrom BenefitCardPlanCard ifknown_2040506: Male pg1203040506: OffCountry of Birth pg8203040506: Date of daypg8 12: Nopg8120304050607: Offundefinedpg8203040506: undefined_2pg8 203040506: SELFYes No03040506: Monthpg8203040506: Date of Month pg8 12: Date of year pg8 12: Nopg8320304050607: OffNon-immigrant (Visa holder)1203040506: OffNone of the above1203040506: OffRace Ethnic GroupUSCitizen Immigrantnoncitizen Enterthedateyoureceived yourimmigrationstatus Month Day Year NonimmigrantVisaholder Noneoftheabove_203040506: Date of Month pg8 13: Date of daypg813: Date of year pg8 13: Yespg8320304050607: OffFullMaidenNamepersonsbirthnamebeforetheyweremarried030607: Yespg8120304050607: OffFamily Health Plus 1203040507: OffFemalepg820304050607: OffImmigrant/non-citizen120304050607: OffYespg8220304050607: OffCityofBirth StateofBirth CountryofBirth_20304050607: Medicaid 120304050607: OffSocial Security Number if you have oneMedicaid FamilyHealthPlus IDNumberfrom BenefitCardPlanCard ifknown_204050607: City of Birthpg820304050607: Country of Birth pg820304050607: StateofBirthpg820304050607: SELFYes No0304050607: Male pg8120304050607: Offundefinedpg820304050607: undefined_2pg8 20304050607: Monthpg820304050607: Date of Month pg8 14: Date of daypg8 14: Date of year pg8 14: Non-immigrant (Visa holder)120304050607: OffNone of the above120304050607: OffRace Ethnic GroupUSCitizen Immigrantnoncitizen Enterthedateyoureceived yourimmigrationstatus Month Day Year NonimmigrantVisaholder Noneoftheabove_20304050607: Is anyone in your household a veteran?pg8yes: OffIs anyone in your household a veteran?pg8no: OffIfyesname: ID Number from Benefit Card/Plan Card, if known: 3: ID Number from Benefit Card/Plan Card, if known: 4: ID Number from Benefit Card/Plan Card, if known: 5: ID Number from Benefit Card/Plan Card, if known: 6: ID Number from Benefit Card/Plan Card, if known: 7: Check Box9: OffCheck Box10: OffName of PersonRow1: Type of IncomeEmployer NameRow1: How Much before taxesRow1: How Often weekly monthlyRow1: Name of PersonRow2: Type of IncomeEmployer NameRow2: How Much before taxesRow2: How Often weekly monthlyRow2: Name of PersonRow3: Type of IncomeEmployer NameRow3: How Much before taxesRow3: How Often weekly monthlyRow3: Name of PersonRow4: Type of IncomeEmployer NameRow4: How Much before taxesRow4: How Often weekly monthlyRow4: Check Box11: OffName of PersonRow1_2: Type of IncomeSourceRow1: How Much before taxesRow1_2: How Often weekly monthlyRow1_2: Name of PersonRow2_2: Type of IncomeSourceRow2: How Much before taxesRow2_2: How Often weekly monthlyRow2_2: Name of PersonRow3_2: Type of IncomeSourceRow3: How Much before taxesRow3_2: How Often weekly monthlyRow3_2: Name of PersonRow4_2: Type of IncomeSourceRow4: How Much before taxesRow4_2: How Often weekly monthlyRow4_2: Check Box12: OffName of PersonRow1_3: Type of IncomeSourceRow1_2: How Much before taxesRow1_3: How Often weekly monthlyRow1_3: Name of PersonRow2_3: Type of IncomeSourceRow2_2: How Much before taxesRow2_3: How Often weekly monthlyRow2_3: Name of PersonRow3_3: Type of IncomeSourceRow3_2: How Much before taxesRow3_3: How Often weekly monthlyRow3_3: Name of PersonRow4_3: Type of IncomeSourceRow4_2: How Much before taxesRow4_3: How Often weekly monthlyRow4_3: nonepg10: OffName of PersonRow1_4: Type of IncomeSourceRow1_3: How Much before taxesRow1_4: How Often weekly monthlyRow1_4: Name of PersonRow2_4: Type of IncomeSourceRow2_3: How Much before taxesRow2_4: How Often weekly monthlyRow2_4: Name of PersonRow3_4: Type of IncomeSourceRow3_3: How Much before taxesRow3_4: How Often weekly monthlyRow3_4: Name of PersonRow4_4: Type of IncomeSourceRow4_3: How Much before taxesRow4_4: How Often weekly monthlyRow4_4: Full Time pg10 1: OffYespg 1023: OffNopg 10: OffYespg 102: OffWho pg 10: Text15: Nopg 102: OffDatepg 10 1: Name of Employerpg 10 2: Nopg 1023: OffYespg 10233: OffPart Time pg10 1: OffUndergraduate pg10 1: OffGraduate pg10 1: OffStudents Name pg 10: Nopg 1024: OffYespg 10234: OffChildsadultsname: Howmuch: HowOftenweeklyeverytwoweeksmonthly: Childsadultsname_2: Howmuch_2: HowOftenweeklyeverytwoweeksmonthly_2: Childsadultsname_3: Yespg 102345: OffHowmuch_3: HowOftenweeklyeverytwoweeksmonthly_3: Nopg 10245: OffNopg 11: OffYespg 11: OffNopg 11 1: OffYespg 11 1: OffName of Insured (primary) 11: Text20: Text21: Enddateofcoverageifendingsoon: undefined_7: undefined_8: Nopg 11 2: OffYespg 11 2: Offundefined_9: Text22: every month1: Off2 times a year5: Offquarterly (4 times a year1: Offonce a year1: OffNopg 11 23: OffYespg 11 23: OffNopg 11 2345: OffYespg 11 234: OffNopg 11 234: OffYespg 11 2345: OffInwhichmonthsofthepreviousthreemonthsdoyouhavemedicalbills: Nopg 11 23456: OffYespg 11 23456: OffNopg 11 234561: OffNamepg12: Yespg 11 234567: OffNopg 11 234567: OffIf yes, who? pg 12: Yespg 11 2345678: OffWhich state? pg12: Whichcounty: Nopg 11 2345679: OffYespg 11 23456789: OffIf yes, who: pg 12 1: Nopg 12: OffYespg 12: OffIf yes, who: pg 12 2: Nopg 12 1: OffYespg 12 1: Offname of applicant with deceased parent or spouse pg 12: Nopg 12 12: OffYespg 12 12: Offundefined_10: OffChilds Name: Name of parent living outside the home: Street_4: CityState: Date of Month pg8 15: Date of daypg8 15: Date of year pg8 15: SSNifknown: Childs Name_2: Name of parent living outside the home_2: Street_5: CityState_2: Date of Month pg8 16: Date of daypg8 16: Date of year pg8 16: SSNifknown_2: Nopg 12 13: OffYespg 12 13: Offname of person applying who is still marriedpg12 1: undefined_101: OffLegal name of spouse living outside of the home: Date of Month pg817: Date of daypg8 17: Date of year pg8 17: Street_6: CityState_3: SSNifknown_3: Check Box31: OffLegal Last NameRow1: Legal First NameRow1: Date of BirthRow1: Social Security Row1: Name of Health Plan You are Enrolling inRow1: Text32: Check Box33: OffOBGYN optionalRow1: Legal Last NameRow2: Legal First NameRow2: Date of BirthRow2: Social Security Row2: Name of Health Plan You are Enrolling inRow2: Check Box34: OffOBGYN optionalRow2: Legal Last NameRow3: Legal First NameRow3: Date of BirthRow3: Social Security Row3: Name of Health Plan You are Enrolling inRow3: Check Box35: OffOBGYN optionalRow3: Legal Last NameRow4: Legal First NameRow4: Date of BirthRow4: Social Security Row4: Name of Health Plan You are Enrolling inRow4: Check Box36: OffOBGYN optionalRow4: Legal Last NameRow5: Legal First NameRow5: Date of BirthRow5: Social Security Row5: Name of Health Plan You are Enrolling inRow5: Check Box37: OffOBGYN optionalRow5: Legal Last NameRow6: Legal First NameRow6: Date of BirthRow6: Social Security Row6: Name of Health Plan You are Enrolling inRow6: Text33: Text34: Text35: Text36: Text37: Check Box38: OffOBGYN optionalRow6: Health Plan pg15: OffSocial Services District pg15: OffProvider Agency pg15: OffQualified Entities pg15: OffEmployerName: