Medical Assistance Application Form (Page 5 of 7) in pdf

MAD 381 Revised

– Page 5



I agree to provide information to the Human Services Department (HSD) which is

The amount of real or personal property (such as land or money) owned by me or

needed to determine if I, (or the person(s) for whom I am applying), can get Medicaid.

the person(s) for whom I am applying, goes up or down.



I agree to let HSD contact other persons or agencies which know about us to get

I or the person for whom I am applying, move into or out of a nursing home or

information which I may not be able to give or to prove.

hospital or move into a different nursing home, return home or move to the home of

another. I understand I must also report if I, or the person(s) for whom I am applying,

PERMISSION TO RELEASE MEDICAL INFORMATION - I give permission for

move out of New Mexico.



medical information about me, or about the person(s) for whom I am applying for

I understand I must report when a person who has needed care in a hospital or

Medicaid, to be released to HSD. I understand that such information includes both

nursing home or who needed another person to care for him/her no longer needs such

social and medical history and the results of any laboratory tests or examinations.

care.

I understand that this information is needed in connection with assistance for which I

I understand that I am responsible for reporting changes that may affect whether I, or

am applying and will be used by HSD's contractors who review medical services and

the person(s) for whom I am applying, can get Medicaid. No other person or agency

pay Medicaid bills.

is responsible for reporting these changes. I understand that purposely failing to

report information such as that listed above within ten (10) days is fraud. I understand

ASSIGNMENT OF MEDICAL SUPPORT - I understand that by signing this application

that HSD can take legal action to get back amounts that Medicaid paid on behalf of

I am assigning to HSD my rights, and/or the rights of the individuals for whom I am

persons who did not qualify for these benefits. I also understand that anyone who

applying for Medicaid, whose rights I can legally assign, to payment for medical

helps to deceive HSD is subject to criminal penalties under the law.

support and other third party payments. I agree to cooperate with HSD in getting

medical support and payments. I understand that this assignment and my cooperation

RIGHT TO A HEARING - I understand that, if a decision on my application is not

are necessary so that I, and/or those persons for whom I am applying, can get

reached within thirty (45) days, HSD will send me a letter explaining the delay. I

Medicaid.

understand that I may ask for a hearing if my application is denied, delayed or

Medicaid benefits are stopped.

I understand that I must give HSD any money I receive for medical services which

have already been paid for by Medicaid. If I fail to do so, I, or the person(s) for whom I

FAIR HEARING- You may request a fair hearing, by telephone, in person, or in

am applying, may lose Medicaid coverage for at least one year AND until the amount

writing, within 90 days of the date the decision was made on your case. You may

owed to Medicaid has been paid back in full.

have another person represent you. If you do not agree with a decision made on any

matter concerning your case, you have the right to look at your case record and other

ASSIGNMENT OF CHILD SUPPORT RIGHTS - I understand that by signing this

documents used to decide your case before the hearing.

application I am assigning to HSD any rights to child support to which I am entitled on

behalf of any child for whom I am applying or receiving Medicaid benefits. When child

PRIVACY - The information you give HSD will be used to determine whether your

support is received, I understand that one third (1/3) of the amount is disregarded in

household is eligible or continues to be eligible to take part in HSD programs. We will

determining eligibility. If this application is for Institutional Care Medicaid, I understand

check this information through computer matching programs. This information will also

that the entire amount of child support is used to figure the amount of the applicant's

be used to make sure that you meet program rules and help us to manage the program.

income which goes to help pay the nursing home.

This information may be given to other Federal and State agencies for official

TRUSTS - I understand that if I, or the person(s) for whom I am applying, have set up

examination, and to law enforcement officials for the purpose of picking up persons

a trust, or are the beneficiaries of a trust, I must give HSD a copy of the trust

fleeing to avoid the law.

document, including all attachments and related information. HSD will analyze the

trust to see if it affects the Medicaid benefits for which I am applying.

If you get benefits that you were not eligible for and have to pay them back, this is called

ESTATE RECOVERY- I understand that, after my death, the HSD can file a claim

a claim. If your household gets a claim against your household, the information on this

application, including all Social Security Numbers, may be given to Federal and State

against my estate to recover the amounts that the state pays or paid on my behalf for

medical assistance provided under the Medicaid program. This process is called

agencies, as well as private claims collection agencies, for claims collection action.

“Estate Recovery.” “Estate Recovery” is required by federal and state law. “Estate

Providing the requested information, including social security numbers of each

Recovery” is required where Medicaid recipients are fifty-five (55) years of age or

household member is voluntary. However, each person applying for assistance must

older and the state makes medical assistance payments on their behalf for nursing

facilities services, home and community based services, and/or related hospital and

give a social security number or it will result in denial of program benefits to each

individual applicant failing to give a social security number. Non-citizen immigrants not

prescription drug services. The amount recovered by HSD will not exceed the amount

requesting assistance for themselves do not need to give immigration status information

of medical assistance payments made on behalf of the Medicaid recipient.

or social security numbers. Any social security numbers given will be used and disclosed

in the same manner as social security numbers of eligible household members.

REPORTING CHANGES – I understand that the information I have given on this

application is used to see if I, or the person(s) for whom I am applying, can receive

We also check with other agencies, the Federal Income and Eligibility Verification

Medicaid. I understand that if the information I have given to HSD changes, I must

Service (IEVS), and the public assistance reporting information system about the

report the new information to my worker within ten (10 days).

information that you give us. This information may affect your household eligibility and

benefit amount.

Examples of changes which must be reported are:



Changes in the amount of income received by me or members of my family

whose income was used in figuring my eligibility or changes in the amount of income

belonging to the person(s) for whom I am applying.

Medical Assistance Application Form Page 5

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