Fillable Form 216 - Medicaid Application printable pdf download

Form 216 - Medicaid Application

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We will consider this application without regard to race,

MEDICAID APPLICATION

FOR COUNTY USE ONLY

color, sex, age, disability, religion, national origin or

Date Received in County Dept

political belief.

Pregnant Woman

Families w/Children – LIM

Check block(s) that

Child(ren) Only – RSM

Chafee Independence Program Medicaid

apply to you:

Were you in foster care on your 18

birthday?

Yes

No In which state?______

PLEASE NOTE: A Face to Face interview is not required for Medicaid applications. Please answer all questions as completely and accurately as possible. If you cannot understand or complete this application,

please notify DFCS staff and assistance will be provided free of charge.

Your Name: (Please Print) FIRST

M.I.

Last

Maiden (if applicable)

Today’s Date:

Mailing Address:

City:

State:

Zip Code:

Residence Address (if different from Mailing Address):

Phone Number(s):

E-mail Address:

Please list all persons living with you for whom you want Medicaid. List yourself if you want Medicaid for yourself.

Is this

Person a

U.S.

Does the

Citizen?

Father of

Does the

(Y/N)

this child

Mother of

(you may

live in

this child

qualify for

your

live in your

Medicaid

Suffix

Sex

Social Security

home?

even if you

First Name

Last Name

(Jr.)

Race

M/F

Date of Birth

Relationship to You

Number

(Y/N)

answer No)

Please list all persons living with you for whom you DON’T want Medicaid. List yourself if you don’t want Medicaid. You do not have to provide a SSN or immigration status information for any

person who is not asking for Medicaid. If provided, we will use the SSN for computer matches with other agencies and it may help us process your child’s application. We will NOT share your

information with the Department of Homeland Security (formerly the INS).

Is anyone in the household pregnant?

Yes

No If yes, who is pregnant? _________________________ Due Date: ____________ Please attach verification of pregnancy if available.

Do you have any unpaid medical bills from the past three months?

Yes

No If yes, which months? _________________________________________________________________

Does anyone in your household have Health Insurance?

Yes

If yes, list Insurance Company and policy number:

Have you or anyone in your household been diagnosed with Breast or Cervical Cancer?

Yes