Application For Kids, Pregnant Women, And Parents (Page 4 of 4) in pdf

5. Does anyone in your home receive other income (such as child support, alimony, Unemployment Compensation benefits, sick benefits,

interest income, Social Security benefits, or other unearned income)?

YES

If yes, complete the following:

PERSON RECEIVING

WHO PROVIDES THE MONEY?

AMOUNT RECEIVED?

HOW OFTEN RECEIVED?

D. HEALTH INSURANCE

1. Does anyone in your home have medical, hospital insurance or Medicare?

YES

PERSONS INSURED

NAME OF COMPANY AND POLICY NUMBER

TYPE OF COVERAGE

Doctor

Hospital

If limited coverage explain:

___________________________________________________

Doctor

Hospital

If limited coverage explain:

___________________________________________________

2. Has anyone in your home lost or dropped health insurance within the past six months?

YES

If yes, provide name(s),

date and reason coverage ended. __________________________________________________________________________________

_____________________________________________________________________________________________________________

3. Is health insurance available for any member of your family through an employer or other group membership?

YES

If yes, name of employer or group: _________________________________________________________________________________

Children How much is the premium for the children? $ ________ per __________

Is the insurance available for:

Self

Spouse

4. Do any of your children have a medical condition that left untreated would result in the death or serious physical injury of the child?

YES

If yes, provide name(s) of child(ren) ___________________________________________________________

5. Is a third party responsible to pay for any of your medical care?

YES

If yes, who? __________________________

6. Please refer to the income guidelines sent with the application. If income and family size fall in the premium group, submit 2 quotes from

private insurance companies of what they would charge for medical coverage for all of your children.

1. $ ____________ per mo. Company ______________________ 2. $ ____________ per mo. Company ______________________

E. ABSENT PARENT INFORMATION (Complete this section if a parent of any of the children is absent from the home.)

NAME

RACE/

SOCIAL SECURITY

BIRTHDATE

PARENT OF WHICH CHILD?

LAST KNOWN ADDRESS

(FIRST, MIDDLE, LAST)

(MAIDEN)

SEX

NUMBER

Do you have a good reason for not cooperating in obtaining support for medical care?

YES

If yes, please explain.

_______________________________________________________________________________________________________________

F. PLEASE READ CAREFULLY AND SIGN BELOW

• I/we agree that I/we must provide Social Security Numbers of all persons applying for MO HealthNet as required by law. The Social Security Number is used

to determine eligibility and verify information.

• I/we agree I/we must be evaluated for the Health Insurance Premium Payment Program (HIPP) if I or members of the household are employed or lost

employment in the last 30 days and the employer or former employer offers group health insurance.

• I/we agree that my/our statements and information provided may be verified.

• I/we will report any changes in circumstances within TEN DAYS of when they happen.

• I/we know that it is against the law to obtain or attempt to obtain benefits to which I am/we are not entitled. Any false claim, statement, or concealment of

any material fact whatever, in whole or in part, may subject me/us to criminal and/or civil prosecution.

• I/we agree that by applying for (and being determined eligible for) MO HealthNet for a child who is deprived of parental support, I/we have assigned all rights

to medical support to the State of Missouri, and that I/we must cooperate in establishing paternity and obtaining medical support, unless I/we have good

cause. Failure to cooperate does not affect a child’s eligibility.

• I/we understand healthcare benefits based on a person being age 65 and over, blind or disabled is not determined by completing this application. If I/we

want eligibility for healthcare benefits explored on the basis of being age 65 or over, blind or disabled, I/we must complete a different application for these

benefits.

• I/we agree that medical information about me and/or my family can be released if needed to administer this program.

• Provided I am/we are found to be eligible for MO HealthNet I/we know the state of Missouri will pay for covered services on my/our behalf and agree the

state may collect payments from any third party (i.e., insurance, estate, etc.) for services paid by the state.

My/our signature below certifies under penalty of perjury that all declarations made in this eligibility statement are true, accurate,

and complete, to the best of my/our knowledge. I/we authorize insurers or employers to release any information on myself or my

dependent(s) needed to determine eligibility for the HIPP program.

SIGNATURE/AFFIDAVIT

DATE

SIGNATURE OF SPOUSE/AFFIDAVIT

DATE

CALL 1-888-275-5908 IF YOU HAVE QUESTIONS

IM-1UA (01-08)

MO 886-2726 (01-08)