Health Insurance Application For Pregnant Women Form Page 2
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3• You must report all changes as soon as
Important Information about Medicaid
possible, but no later than 10 days after the
This Medicaid form is only for pregnant women.
change.
The Department of Children and Families will tell
• You must NOT take part in any misuse of your
you if you are eligible for Medicaid.
medical assistance.
• You have the right to apply on the same day
Health Insurance
you contact the office about the Medicaid
program.
For Pregnant Women
• You have the right to receive Medicaid, if you
are eligible.
• You must help us determine your eligibility by
giving us information or allowing us to obtain
it from others, including data matches.
• You must give us complete and correct
information on all members of your household
at the initial application and every contact.
• You must give us your Social Security Number
(SSN) and your citizenship status. SSNs are
used by the Department for identity
Return completed form
verification, income and eligibility verification
and other purposes related to the
to local office address
administration of our programs. You do not
have to give us the SSNs or citizenship status
shown below:
of others in your home. If you do provide us
with their SSNs, this information will only be
used to verify income. SSNs are not shared
with the INS. If the SSNs of others are not on
the application, you may need to provide proof
of their income.
• Your age, creed, disability, marital status,
national origin, color, race, sex, religious or
political beliefs will not affect your request or
service.
• You have the right to appeal any decision
made on your case.
• If you misrepresent the truth on purpose, or
A Special Medicaid Program
help someone else to misrepresent the truth on
purpose, you can be punished under federal or
state law or both. If you get medical
For information or help in filling out this
assistance for which you do not qualify, you
application call your local DCF office
may have to repay the cash value of that
Remember:
assistance. You may also be subject to other
civil penalties.
Prenatal care is
• You must assign your rights to third party
payments and cooperate in reporting health
important for you
insurance coverage.
and your baby.
CF-ES 2700, page 2
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