Mad 023 - Medicaid Application For Women, Children, And Families printable pdf download

MEDICAID APPLICATION

FOR

WOMEN, CHILDREN, AND FAMILIES

Si Ud. necesita este formulario en español, comuníquese con su trabajador(a). Intérpretes están disponibles gratuitamente

Programs of Medical Assistance

Provides Medicaid to parents or caretaker relatives with dependent children

under age 19, even if the household does not qualify for cash assistance, or

does not wish to apply for cash assistance. Medicaid is totally separate from

JUL FAMILY MEDICAID

cash assistance. Receiving Medicaid benefits will not count toward the cash

assistance time limit.

Provides coverage for children under age 19. Some children may be eligible

under the Children’s Health Insurance Program (CHIP). CHIP children have

MEDICAID FOR CHILDREN ONLY

small co-payment requirements. Native American children who are eligible for

CHIP do not make co-payments.

Covers only those services that are related to family planning for men and

FAMILY PLANNING FOR MEN

AND WOMEN

women of child bearing age.

Covers only those services that are related to the pregnancy. Coverage for

these services is provided for up to two months after the month in which the

PREGNANT WOMEN

child is born or the pregnancy ends.

There are other Medicaid programs that require an application different from this one.

Federal regulations require that all individuals receiving Medical Assistance provide specific documents that verify Citizenship

or Legal Permanent Status and Identity. This is a one-time process. A U. S. birth certificate is the easiest way to establish proof

of citizenship (other types of proof are listed below).

For individuals born in New Mexico every effort will be made to help you verify your birth certificate through the New Mexico Department

of Health. We will provide you information necessary to obtain birth certificates for those household members born outside of the state of

New Mexico.

Remember to provide proof of the

One or more of the following may be used as proof… ▼

following with your application: ▼

Identity

Copy of driver’s license, Government ID with photo, INS letter or immigration card

Copy of U.S. passport, Certificate of Naturalization, Certificate of Citizenship, U. S. Birth

U.S. Citizenship

certificate, certification of birth issued by the Department of State, Certificate of Indian

Blood. Do not send your Social Security Card.

Legal Immigrant Status

Copies of Immigration card, or INS or Department of Homeland Security letter

Current check stubs or Copies of Paychecks for the past 30 days or letter from your

employer

Income

Copy of your check or award letter from Social Security, Veteran's, Retirement, or other

(for you and your spouse)

sources

Self-employment records such as Income Tax forms or Personal Wage Records

Health Insurance

Copies of ID Card or Letter from your Health Insurance Company

Pregnancy Due Date

Medical Statement of Due Date

(if it applies to you)

Cat.

Application Date

Date Mailed

Date Received

Status ❏ Application

Former Recipient ❏

Yes

ISD Office

Use Only

❏ Redetermination

❏ No

PE Interviewer Name

PE Interviewer’s Site

PE Interviewer Phone

Date Mailed to ISD

PE/MOSAA

Office

Use Only

MAD 023 Revised 03/05/12

Mad 023 - Medicaid Application For Women, Children, And Families

Related Articles

Related forms

Related Categories