Medical Assistance Application Form printable pdf download

MEDICAL

APPLICATION/REDETERMINATION of ELIGIBILITY for MEDICAL ASSISTANCE

ASSISTANCE

Of Aged, Blind and Disabled Individuals

DIVISION

If you need help with this form just ask your caseworker. Free interpreters are available. Si necesita ayuda para completar este formulario, pídale su trabajador(a).

Intérpretes están disponibles gratuitamente.

PLEASE READ ALL QUESTIONS. The applicant is the person who wants Medicaid. If the applicant is married, we need certain information about his/her spouse. If the

applicant is a child, we need certain information about his/her parents. We refer to the applicant on the form by using the words “you” or “your.” The answers given will be used

to determine eligibility. You may ask a friend, relative or someone at the county office for help in completing the application. If information is incomplete or is unclear, you will

be asked to provide further information.

This application is for:

 Nursing Home  ICF-MR  Medically Fragile Waiver  Aids Waiver  Disabled & Elderly Waiver  Developmentally Disabled Waiver  Brain Injury

A PPL I C A NT I NF OR M A T I ON

Name-Last

First

Middle Initial

Sex

Age

Birth Date

FOR COUNTY

 F

OFFICE USE ONLY

 M

GEO

ADMIN

Mailing address- Street No./PO Box /R. Rt.

City

State

Zip Code

Telephone Number

Date Received

Home address or directions to your home:

Are you in a nursing home or hospital?  YES

If, YES, Name of Facility:

CATEGORIES

 NO

Do you intend to remain in

 YES

Are you a resident of another state?

If, YES, name state where you are a resident:

 YES

ASSIGNED TO:

New Mexico?

 NO

Social Security Number

Medicare Claim Number

Railroad Retirement Number

Indian Census Number

REFERRAL TO DDS:

ISD 305 COMPLETED

CITIZENSHIP

Registration Number (if legal alien)

Date Submitted

United States citizen?  YES

 YES

If, NO, have you been legally admitted for US Residence?

 NO

MARITAL STATUS – Check one

SSI

 SINGLE

 MARRIED

 WIDOWED

 DIVORCED or LEGALLY SEPARARTED

 SEPARATED – Without legal action

Eligible Date

SPOUSE I NF OR M A T I ON

Ineligible Date

Name – Last

First

Middle Initial

Sex

Age

Birth Date

 F

Referral Date

 M

Medicare Claim Number

Railroad Retirement Number

Indian Census Number

SCANS

Mailing address- Street No./PO Box /R. Rt.

City

State

Zip Code

Telephone

SDX ______________

Number

WDX ______________

Home Address or directions to your home:

TPQY Mailed

 YES

Is the spouse in a nursing home?

If, YES, Name of Facility:

 NO

If you have a disability:

If you are a person with a disability and you need this information in an alternative format, or require a special accommodation to participate in any public hearing, program

or services, please contact the NM Human Services Department toll-free at 1-800-432-6217 or TDD 1-800-609-4TDD or through the New Mexico Relay System TDD at 1-800-659-8331. The

Department requests at least 10 days advance notice to provide requested alternative formats and special accommodations. (04/23/01)

MAD 381 Revised