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APPLICATION FOR HOOSIER HEALTHWISE
FOR CHILDREN AND PREGNANT WOMEN
*DFRHHEE01*
State form 43202 (R8 / 8-12) / FI 2030
1. Tell us about the members of your family living in your household. Put your name first, and list only children,
.
spouses, and parents.
Place a in the last column if that person is applying for health coverage
Date of
Social Security Number
Marital
Race
Sex
Relationship
Citizen of U.S.?
if
Name (First, MI, Last)
Birth
Status
Yes / No
to You
applying
mm/dd/yyyy
*
*
Self
* See #6 and #8 of Rights and Responsibilities.
2. Tell us your address and telephone number.
Home address
City
State
Zip code
County
Mailing address, if different
City
State
Zip code
County
E-mail address if you have one
Telephone number
Other telephone number where you can be contacted
(
)
(
)
Do you want to receive automated calls from our agency?
Yes
No
(Examples of calls you may receive are appointment reminders or due dates for requested documents.)
3. Health Plan Selection
If your application is approved, you will be enrolled in one of our health plans. If you have made your selection, please mark
the box next to your chosen plan.
Anthem Blue Cross Blue Shield
MHS
MDwise
Provider directories are available on the health plan websites. If you have given us your e-mail address above, we will send
Yes No
an electronic copy to you. Do you need a paper copy instead?
If you have questions about how to choose your health plan or would like the provider directory before being assigned to a
health plan, please call the Hoosier Healthwise Helpline at 1-800-889-9949.
4. Do the applicants live in Indiana? Yes
No
5. Does any applicant have a court-appointed legal guardian? Yes No If yes, who? ______________________
6. Are any of the applicants pregnant? Yes No
Name of expecting mother
Date Pregnancy Began
Due Date
Number of unborn babies
7. Are any of the applicants blind or disabled? Yes No (Enter a for blind or disabled.)
Name of applicant
Blind
Disabled
Name and Address of the doctor
8. Do you pay for child care?
Do you pay for care of an incapacitated adult?
Yes
No
Yes
No
9. Does anyone living in the household pay support payments?
Yes No
Completed by Enrollment Center: Date of application
: __________ Center’s Code:______ Interviewer: ______________________
(month,day,year)
Completed by DFR: Date received
: ______________ Case Number: ___________________________
(month,day,year)
DFRHHEE01