2003 Application & Renewal Form (Page 4 of 6) in pdf

Section L: Read Carefully and Sign Below

I UNDERSTAND

• That there is a grievance process if I disagree with an action taken on my case;

• That all information given on this form is subject to verification by federal, state and local officials;

• That all information given on this form is confidential and the Department of Social Services (DSS) or its agent will only use this information to administer DSS programs;

• That by receiving medical assistance, I allow the state to recover the cost of my medical bills, which may have been covered by other insurance, directly from the insuring

company;

• That the state may recover from the proceeds of a lawsuit, based upon negligence, the cost of accident-related medical services paid by the state;

• That any payment made by the state on behalf of an enrollee as a result of a false statement, misrepresentation or concealment of or failure to disclose income or health insurance

coverage by an applicant responsible for maintaining insurance may be recovered by the state; and

• That if I have knowingly given incorrect information I may be subject to penalties for false statements and larceny as specified in the Connecticut General Statutes sections

53a-122, 53a-123, 53a-157b, and 17b-97, as well as penalties under Federal Law.

I AGREE

• To notify DSS or its agent within 10 days of all changes in family circumstances, for example, income, medical insurance, address, residence of child, or household size;

• To cooperate with federal, state, and local officials by providing authorizations, documents and other proof regarding the information that I have provided on this form;

• To cooperate with federal and state personnel in a Quality Control Review;

• To not alter, trade, lend, or sell my medical services card and/or the medical services card of any individual for whom I applied for health insurance, and to have the Department

or its agent file Medicare claims and pursue appeals.

• To allow DSS or any health insurer, provider, or other entity providing services to me or my family under the HUSKY program to release information about me or my family as

necessary for the delivery of HUSKY program services and the administration of the HUSKY program, as permissible by federal or state law.

I CERTIFY

• That I have read this form or have had it read to me in a language that I understand and the information given on this form is true and complete to the best of my knowledge.

_____________________________________________________

________________________________________________________

SIGNATURE

Date

Interpreter's Signature

Date

_____________________________________________________

If someone helped the applicant complete this form, this person must sign also.

Witness' Signature (if signed with an X)

Date

________________________________________________________

Helper's Signature

Date

OFFICIAL USE ONLY

If someone completed this form on the applicant's behalf, this person must sign also.

___________________________________________________

________________________________________________________

Reviewed By

Date

Representative's Signature

Date

Return this form in the self-addressed envelope provided. If no envelope was provided, mail the completed forms to:

HUSKY PROGRAM, P.O. BOX 280747, EAST HARTFORD CT 06128

How did you hear about the HUSKY Program?

❑ TV

❑ Radio

❑ Newspaper

❑ Doctor's Office

❑ InfoLine

❑ Presentation

❑ Other_____________________________________

HUSKY medical assistance coverage will not be denied due to a pre-existing medical condition.

This application will be considered without regard to race, color, gender, age, physical or mental disability, religious creed, national origin, sexual orientation, ancestry, language barriers, or

political beliefs.

IF YOU HAVE ANY QUESTIONS ABOUT THIS APPLICATION OR NEED HELP COMPLETING IT, CALL 1-800-656-6684.

W-1HUS (Revised 4/2003)