Mad 023 - Medicaid Application For Women, Children, And Families Page 2
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Applicant Information
1.
Complete this application.
2.
Bring or mail this application to the ISD office serving your area.
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3.
Provide needed items to help you qualify for the programs.
4.
If the documents are incomplete, you will be asked to provide the needed information.
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5.
A decision on your application will be made within 45 days, unless you ask for more time to get information.
6.
You will be sent a letter about your application.
You may request a fair hearing, by telephone, in person, or in writing, within 90 days of the date the decision was
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made on your case. You may 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 documents used to
decide your case before the hearing.
All programs administered by the Human Services Department (HSD) are equal opportunity programs. If you
believe you have been treated unfairly because of race, color, national origin, age, disability, and where applicable,
sex, marital status, familial status, parental status, religion, sexual orientation, genetic information, political 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
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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)
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The information I give during the application process is used to determine eligibility. It is my responsibility to report
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only changes that would result in a loss of eligibility. This includes increase in income above the program limits,
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persons living with me, moving out of state, and in some cases other health insurance.
I understand that by getting JUL or CHIP Medicaid benefits for myself and/or other persons, I automatically give HSD
all rights to medical support and to payment for medical care from a third party. A third party can include an absent
parent, an insurance company, or another person who must pay for medical care and services.
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I understand that I must help HSD:
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Identify the father of a child who gets Medicaid.
Identify any third parties who may have to pay for medical care and services.
I understand that if I do not help HSD, I may not get Medicaid benefits or may lose my benefits, unless I can show a
good reason for not helping HSD.
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I understand that all information I give to HSD is confidential. Information will only be used for eligibility purposes or to
provide services. By law, confidential information may be released to other agencies that manage federal programs.
The information you give HSD will be used to determine whether your household is eligible or continues to be eligible to take
part in HSD programs. We will check this information through computer matching programs. This information will also be
used to make sure that you meet program rules and help us to manage the program.
This information may be given to other Federal and State agencies for official examination, and to law enforcement officials
for the purpose of picking up persons fleeing to avoid the law.
If you get benefits that you were not eligible for and have to pay them back, this is called 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
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Federal and State agencies, as well as private claims collection agencies, for claims collection action.
Providing the requested information, including social security numbers of each household member is voluntary. However,
each person applying for assistance must 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 requesting assistance for themselves
do not need to give immigration status information 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.
We also check with other agencies, the Federal Income and Eligibility Verification Service (IEVS), and the public assistance
reporting information system (PARIS) about the information that you give us. This information may affect your household
eligibility and benefit amount.
MAD 023 Revised 03/05/12
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