Florida Medicaid/medicare Buy-In Application Form
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MEDICAID/MEDICARE BUY-IN APPLICATION
Page 1
Demographic Information:
Please complete all information for you and your spouse. If no spouse, indicate “None”.
Your Name (Applicant):
First
MI
Last
Your Social Security Number:
Sex:
Male
Female
Name of Spouse:
First
MI
Last
Spouse’s Social Security Number (if applying):
Sex:
Male
Female
Do you and your spouse live together?
Yes
No
Your Medicare claim number:
Spouse’s Medicare # (if applying):
Living Address:
______________________________________________________________________________________________
Number
Street
Apt #
City
Zip Code
Mailing Address: ______________________________________________________________________________________________
Number
Street
Apt #
City
Zip Code
Telephone Number:
Telephone #
Contact Person: __________________________________________________________________________
(Other than Yourself)
First
Last
MI
______________________________________________________________________________________________
Number
Street
Apt #
City
Zip Code
___________________________________
Telephone #
Date Stamp: (Official DCF use only)
Relationship of Contact Person to you:___________________________________________
Do you want eligibility determined for the
three months before the month of application?
Yes
No
Technical Information:
Please complete all information for you and your spouse.
Date of Birth:
________________
________________
You
Spouse
Are you a U.S. Citizen?
You:
Spouse:
Yes
No
Yes
No
If not a citizen, provide alien number and status: __________________________________ ; __________________________________
You
Spouse (if applying)
Do you intend to remain in the State of Florida?
You:
Spouse:
Yes
No
Yes
No
Do you and/or spouse have any other insurance other than Medicare?
You:
Spouse:
If Yes, Complete the following information:
Yes
No
Yes
No
______________________________________________________________________________________________________________
Name of Other Insurance Company
Other Insurance Policy Number
______________________________________________________________________________________________________________
Address of Other Insurance Company
Who is Covered by This Insurance
CF-ES 2282, PDF 07/2006
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Parent category: Medical