Form 94 - Medicaid Application Form

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We will consider this application without regard to race,
MEDICAID APPLICATION
FOR COUNTY USE ONLY
color, sex, age, disability, religion, national origin or
Date Received in County Dept
Families w/Children – LIM
political belief.
Pregnant Woman
Child(ren) Only – RSM
Check block(s) that
Chafee Independence Program Medicaid
th
birthday?  Yes  No In which state?______
apply to you:
Were you in foster care on your 18
PLEASE NOTE: A Face to Face interview is not required for Medicaid applications. Please answer all questions as completely and accurately as possible. If you cannot understand or complete this application,
please notify DFCS staff and assistance will be provided free of charge.
Today’s Date:
Your Name: (Please Print) FIRST
M.I.
Last
Maiden (if applicable)
Mailing Address:
City:
State:
Zip Code:
Residence Address (if different from Mailing Address):
Phone Number(s):
E-mail Address:
Please list all persons living with you for whom you want Medicaid. List yourself if you want Medicaid for yourself.
Is this
Person a
U.S.
Does the
Citizen?
Father of
Does the
(Y/N)
this child
Mother of
(you may
live in
this child
qualify for
your
live in your
Medicaid
Suffix
Sex
Social Security
home?
home?
even if you
First Name
MI
Last Name
(Jr.)
Race
M/F
Date of Birth
Relationship to You
Number
(Y/N)
(Y/N)
answer No)
Please list all persons living with you for whom you DON’T want Medicaid. List yourself if you don’t want Medicaid. You do not have to provide a SSN or immigration status information for any
person who is not asking for Medicaid. If provided, we will use the SSN for computer matches with other agencies and it may help us process your child’s application. We will NOT share your
information with the Department of Homeland Security (formerly the INS).
Is anyone in the household pregnant?
Yes
No If yes, who is pregnant? _________________________ Due Date: ____________ Please attach verification of pregnancy if available.
Do you have any unpaid medical bills from the past three months?
Yes
No If yes, which months? _________________________________________________________________
Does anyone in your household have Health Insurance?
Yes
No
If yes, list Insurance Company and policy number:
No If yes, have you received Women’s Health Medicaid previously?
Have you or anyone in your household been diagnosed with Breast or Cervical Cancer?
Yes
Yes
No
Form 94 (11/10)

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