Redetermination Notice For Aged, Blind, Disabled Medical Assistance Form printable pdf download

Redetermination Notice for Aged, Blind, Disabled Medical Assistance

Dear [4],

It is time to see if you are, or your family is, still eligible for your medical benefits. Please review the current information we have in

Section I below. If there are changes to current information or missing information, please complete Section II and return the

information to us or you can enter your changes on PEAK Redetermination at [5].

You may receive two separate Medical Assistance Redetermination Notices due to your household circumstances. If you have

changes to each notice, please report changes for both notices.

If you do not have changes, do not do anything. We will check to see if you are still eligible for benefits with the information we

have. You may need to give us documents to see if you are, or your family is, still eligible. If we need documents from you, we will

let you know.

You must report your changes. If you have changes and don’t report them, you may have to pay back medical payments paid

by Medicaid or CHP+.

Section I: Your information on file

(Information below is to be pre-populated (List all household members that are in the home.) instructions for development only)

Client's Name (First {11a], Middle Initial [11B], Last [11c], Suffix [11d]), Client's Date of Birth [12], Requesting Medica1 Assistance

Y/N [13]

Employed Y/N [14], Employer Name [15], Income (Type [16], Amount [17], & Frequency [18])

Self –Employed [19] (Amount [20] & Frequency [21])

Unearned Income Y/N [22] (Type [23], Amount [24], & Frequency [25])

Expenses Y/N [26] (Type [27], Amount [28])

Resources Y/N [29] (Type [30], Fair Market Value [31]), Amount Owned [32]

Roomers/Boarders Y/N [33] (Amount [34] & Frequency [35])

Section II: Report Your Changes-

I have No changes. (If you do not have changes, do not do anything)

I am reporting the following change(s) (Check the boxes next to each change):

Change of address or phone number: ___________________________________________

______________________________________________________________________________

Pregnancy:

Pregnant woman's name: _______________________________ Due date: ___________

Person leaving my home:

Name: ____________________________________________ Date of birth: ___________

Date left my home:__________________________________________________

Relationship of this person to you:______________________________________

Person added to my home:

Name: ______________________________________________ Date of birth: _________

*If this person is requesting Medical Assistance, please include the information below.

Social Security Number or Date Applied:__________________________________

Date entered my home:_______________________________________________

Relationship of this person to you:______________________________________

Redetermination Notice For Aged, Blind, Disabled Medical Assistance Form