Immigration Status Verification Checklist
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1IMMIGRATION STATUS VERIFICATION CHECKLIST
Maryland Health Connection ID: _____________________________________
(Please write your MHC ID number above)
Please complete the below checklist when returning copies of your verification documents.
If you are a U.S. Citizen or U.S. National, please provide us with
a copy of at least one document that is
listed:
Birth Certificate (Form FS-545 or DS-1350)
Hospital/Doctor Records Established at Time of Birth (Form 1184)
Consular Report of Birth Abroad issued by the U.S. Department of State (Form FS-240)
U.S. Passport or Passport Card (excludes Limited Validity Passports issued for less than 5 years)
Certificate of Citizenship (N-560, N-561)
Certificate of Naturalization (N-550, N-570)
Native American/Alaska Native Tribal Documents (issued by federally recognized tribe, including
Tribal Enrollment Card, Certificate of Degree of Indian Blood and Tribal Census Document)
Other (please indicate)________________________________________________________
If you are not a US Citizen, but lawfully present in the U.S, please provide us with
a copy of at least one
document that is
listed:
Foreign Passport with Reentry Permit (I-327)
Refugee Travel Document (I-571)
Certificate of Eligibility for Nonimmigrant (F-1) Student Status (I-20)
Certificate of Eligibility for Exchange Visitor (J-1) Status (DS-2019)
Valid, unexpired Permanent Resident Card issued by the U.S. Department of Homeland Security
(Form I-551)
Unexpired Employment Authorization Documents (Form I-766)
Temporary Resident Card (I-688)
Employment Authorization Card (I-688A)
Employment Authorization Document (I-688B)
Arrival/Departure Record (I-94) in Unexpired Foreign Passport
Other (please indicate)________________________________________________________
Deadline -
To be eligible to continue your enrollment in a health plan through Maryland Health
Connection, you must provide the requested documentation by April 10, 2015.
Language services are available to assist you, call 1-855-642-8572 (TTY: 1-855-642-8573). Servicios de
traductor están disponibles para asistirles, llame al 1-855-642-8572 (TTY:1-855-642-8573).
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