Medical Assistance Application Form Page 6
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7MAD 381 Revised
– Page 6
CIVIL RIGHTS - All programs administered by the Human Services Department (HSD)
CONFIDENTIALITY - I understand that all information I give to HSD is confidential.
are equal opportunity programs. If you believe you have been treated unfairly because
Information will only be used for eligibility purposes or to provide services. By law,
of race, color, national origin, age, disability, and where applicable, sex, marital status,
confidential information may be released to other agencies that manage federal
familial status, parental status, religion, sexual orientation, genetic information, political
programs.
beliefs, reprisal, or because all or part of an individual’s income is derived from any
public assistance program, you may file a complaint. Complaints of discrimination may
be filed with the New Mexico Human Services Department central office or the local
Human Services county office. Complaints of discrimination about the SNAP program
may be filed with the USDA, Director, Office of Civil Rights Room 326 W, Whitten Bldg.,
1400 Independence Ave, S.W. Washington, DC 20250-9410 or call (202) 720-5964
(voice and TDD). Complaints of discrimination about Cash Assistance and Medical
Assistance programs may be filed with the Office of Civil Rights, Department of Health
& Human Services, 1301 Young Street, Suite 1169, Dallas, TX 75202 or call (800) 368-
1019 (voice) and (214) 767-8940 (TDD) (09-02-09)
I UNDERSTAND THE QUESTIONS ON THIS APPLICATION. MY ANSWERS ARE CORRECT AND COMPLETE TO THE BEST OF MY KNOWLEDGE
Applicant’s Signature
Signature of Witness (Witnessed only if applicant signs by mark or thumbprint)
Date
Signature of Applicant’s Representative
Signature of Witness
Date
Mailing Address of Representative – Street No./PO Box/R.Rt.
City
State
Zip Code
Work Telephone Number
Home Telephone Number
NOTICE: The law provides for a fine of up to $5,000 or imprisonment of up to 10 years for anyone who helps take anything of value, including public assistance, by deliberately withholding or
giving false information.
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