Health Insurance Application For Pregnant Women Form

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Office Date Received Stamp:

Health Insurance Application for Pregnant Women

Clear

A Special Medicaid Program

Name:

First

M.I.

Last

Maiden Name

Area Code

Phone Number

(

)

Residence:

Number

Street

Apt. No.

City

County

State

Zip Code

Mailing Address (Required if different from above):

If no home phone, number where you can be reached

(

)

1. Who in your home is pregnant? ___________________________________________________________________

2. Does she have Medicaid?

Yes

3. Has a Healthy Start Screening been done?

Yes

Don’t Know

If no, or don’t know, ask your doctor for one.

4. Estimated Delivery Date:________________

5. List all of the people who live in your home (write your name first):

** Only the pregnant woman must provide her Social Security Number and her citizenship or INS ID number.

Relationship To

Applied for

** Social Security

US Citizen?

** If no, give

Pregnant

Medicaid?

First

M. I.

Last

Date of Birth

Race

Sex

Date of Entry

Number

Yes

INS ID Number**

Woman

Yes

(Self)

If there are more people in the home, attach the information on another sheet of paper, including information about their income.

6. Does the father of the unborn child live in the home?

Yes

If yes, please list his name:___________________________________________________________

7. You must provide all information on everyone listed in Item 5 above. But, if you are 21 or older, you can omit information on your parents and your siblings.

Name of Person

Gross Income

How Often Paid This Amount?

Income Source

Additional Information

Receiving Income

(Before Deductions)

(w eekly, biw eekly, monthly)

Current Job: Employer’s Name

Employer's Address/Phone Number:

Current Job: Employer’s Name

Employer's Address/Phone Number:

Child Support

Child Care Costs for Job:

Social Security/SSI

Paid by:

Paid to:

Unemployment Benefits

Child(ren) paid for:

Other:

Amt. Paid: $

How often:

8. Does the pregnant woman have health insurance?

Yes

No.

If yes, give the name of the insurance company:_________________________________________________

9. Does the pregnant woman have Medicare?

Yes

No.

If yes, what is the Medicare number? ____________________________________________

10. Are there any unpaid medical bills for the pregnant woman for the last three months?

Yes

No.

If yes, what months:____________________________________________

PLEASE NOTE: You are required to provide proof of your pregnancy. To ensure quick processing of your application, attach proof from a qualified health professional.

CERTIFICATION AND AUTHORIZATION: I certify under penalty of perjury that the information provided on this application is true and correct to the best of my knowledge. I

understand that the information provided shall be kept confidential in accordance with Florida and federal law. I authorize the release of financial and medical information for the

purpose of determining eligibility, and I authorize the Medicaid, MomCare, Healthy Start Care Coordinator, WIC, and DCF programs or their agents to contact me or my health care

providers concerning my participation in prenatal care and delivery programs. I understand that information I have provided will be subject to verification, which may include

computer file matching and that I may be requested to provide additional information. I have read and understand my rights and responsibilities. As a condition of participation in

the Medicaid program, the applicant consents to the review and release of all medical records deemed necessary in the administration of the state Medicaid plan.

Signature of Applicant:______________________________________________________________________________________

Date:__________________

CF-ES 2700, PDF 05/2010

[65A-1.704, F.A.C.]