Form 403 - Diamond State Health Plan - Application For Health Insurance Page 2
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3
4*Race Code:
I=American Indian/Alaskan Native; B=Black/African American;
1. HOUSEHOLD MEMBERS: Tell us who lives in your household
PI=Native Hawaiian/Pacific Islander; W=White; A=Asian
**Ethnic Code:
H=Hispanic/Latino; N=Non-Hispanic/Latino
Legal
*Race /
Social Security
Alien and
How is this person
Are you
State
U.S.
**Ethnic
Number
Date of
related to you?
applying
and
Citizen
Last Name
First Name
M
Sex
Group
Entry into
(spouse, child,
for this
Date of
For
I
U.S.
stepchild, friend)
person?
Birth
applicants
Optional
For applicants
For
applicants
SELF
Yes
No
Yes No
Yes No
Yes
No
Yes
No
Yes No
Yes
No
Yes
No
Yes No
Yes
No
Yes
No
Yes No
Yes
No
Yes
No
Yes No
Yes
No
Yes
No
Yes No
Yes
No
Yes
No
Yes No
Answer the questions below if a parent of any child applying does not live in your home. This is for medical support only.
See explanation on the back of this form. If you do not answer, your children may still be eligible.
Child’s Name
Absent Parent’s Name
Absent Parent’s Address
Absent Parent’s Employer
Is anyone in the household pregnant? Name:____________________________Due Date:________How many babies are expected? ____________
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Parent category: Legal