Mad 023 - Medicaid Application For Women, Children, And Families Page 3
ADVERTISEMENT
1
2
3
4
5Page 3
If you are a person with a disability and you require this information in an alternative format, or require a special accommodation to
participate in any public hearing, program or services, please contact the NM Human Services Department toll-free at 1-800-432-6217 or
through the New Mexico Relay System TDD at 1-800-659-8331 or by dialing 711. The Department requests at least 10 days advance
notice to provide requested alternative formats and special accommodations.
1. Tell Us About You
If you need help filling in this application or in getting the needed information, contact your local ISD office.
If you are applying for someone else, complete this section for that person.
First Name, Middle Initial, Last Name
E-Mail Address
Best Time to Contact You
Street Address
City
State
Zip Code
Telephone number
(
)
If your mailing address is different, please fill it in below. If not, please leave blank.
Street or PO Box Address
City
State
Zip Code
2. Tell us about the people you are applying for
Please fill in the spaces below for everyone who lives in your home. If you need more space, attach a separate piece of paper.
Provide Social Security Numbers and Citizenship ONLY for those who are applying for assistance.
List names and information for yourself and all the
Fill out this section only for each person applying.
people who live with you:
State & County
Citizenship
Race &
Maiden Name
Name
Sex
Date of
of Birth
Immigration
Relationship
Ethnicity
of Mother of
SSN #
(First and Last)
M/F
Birth
Status 1-14
(Optional)
Each Applicant
(See Below)
(Self)
1.
2.
3.
4.
5.
6.
7.
8.
Citizenship/Immigration Status: For each person applying for help, choose from the numbers below that best describes their U.S.
►
Citizenship or Immigration Status and write the number above.
1. U.S Citizen
2. Lawful Perm Resident (LPR)
3. Refugee
4. Asylee
5. Cuban Haitian Entrants
6. Amerasians
7. Paroled to U.S. – 1 year
8. Withholding of Deportation
9. Battered Woman/Child
10. Veterans, Active Duty Military
11. Hmong or Lao Tribe
12. Canada/Mexico American Indian
13. Human Trafficking Victim
14. Other
Please answer the following questions about the people you listed in the above.
1.
Is anyone in the household pregnant? Who?_____________________________ Due Date ______________
Yes
No
2.
Has anyone in the household received medical services within the last 3 months which have not been paid?
If yes, please list the members who have the bills and for which months.
Yes
No
___________________________________________________________________________________________
3. Does anyone in your household have health insurance?
Yes
No
4. Has insurance for a child or children been dropped in the last 6 months? If yes, provide name(s) of child(ren)
and date(s) the insurance was dropped:
Yes
No
a._____________________________; b._____________________________; c._________________________
Provide reason insurance was dropped:___________________________________________________________
MAD 023 Revised 03/05/12
ADVERTISEMENT
0 votes
Related Articles
Related forms
Application To The Probate And Family Court Department For Appointment As Guardian Ad Litem
Business
Application For A Possession And Acquisition Licence Under The Firearms Act (for Individuals Aged 18 And Over) - Canada
Business
Related Categories
Parent category: Medical