Odm 07103 - Application For Help With Medicare Expenses - Ohio
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2Ohio Department of Medicaid
APPLICATION FOR HELP WITH MEDICARE EXPENSES
Medicaid can assist you in paying costs connected to Medicare. All or part of your Medicare expenses can be
paid by the Qualified Medicare Beneficiary (QMB), Specified Low-income Medicare Beneficiary (SLMB),
Qualified Individuals (QI-1), or Qualified Disabled Working Individuals (QDWI) categories of Medicaid. Please
complete this application and submit it to your local County Department of Job and Family Services (CDJFS) to
apply for this type of assistance.
A face-to-face interview is not required.
You must supply proof of U.S. citizenship or alien status, income, and resources.
This is not an application for cash or food assistance.
If you would like to apply for any other kind of help, or have your eligibility for other forms of Medicaid
evaluated, please inform your local ODM.
If you have questions or need assistance completing this application, please call your local CDJFS or
call the Medicaid Consumer Hotline at 1-800-324-8680 or TDD 1-800-292-3572.
VOTER REGISTRATION APPLICATION ATTACHED - ASSISTANCE AVAILABLE
If you are not registered to vote where you live now, would you like to apply to register to vote here today?
YES, I want to register to vote.
NO, I do not want to register to vote.
If you do not check either box, you will be considered to have decided not to register to vote at this time.
Name of Applicant (First, MI, Last)
Phone Number
Date of Birth
Street Address
Social Security Number
City
State
Zip
Social Security CLAIM Number
OH
Place of Birth
Race/ethnicity (optional)
American Indian/Alaskan Native
Asian
Hispanic/ Latino
Black/African American
Not Hispanic/ Latino
Are you a U.S. citizen?
Yes
No
Native Hawaiian/Other Pacific Islander
If not, you will be asked to show an alien
White
registration card and INS forms.
Is the Medicare Part B premium taken out of
Marital status
Single
Married
Divorced
Widowed
your Social Security check?
If you are married, does your spouse receive Medicare?
Yes
No
Does your spouse want help with Medicare expenses?
Yes
No
Yes
No
If yes, spouse's name _____________________________________________________
If yes, when did the withdrawal begin?
_________________
Date of Birth ______________
Social Security Number ________________________
Health Coverage. List any health insurance or health coverage you have:
Insurance Company/Plan
Policy Number
Monthly Cost
What Does the Policy Cover?
$
$
$
Income. List all of your income below, including but not limited to income from annuities, Social Security, SSI,
VA benefits, spousal support, employment, retirement, or money regularly received from friends and family.
Include all of your spouse's income.
Employer/Source of Income
Gross Amount
How Often Is Income Received?
$
$
$
$
ODM 07103 (7/2014)
Formerly JFS 07103
Page 1 of 2
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