Form Mdhs-Ea-901 Medi - Application
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1
2
3
4FOR OFFICE USE ONLY
application
Case Name
Case Number
County Number
85
87
88
91
99
FOR MISSISSIPPI HEALTH BENEFITS
Date Received
If you or your children have Medicaid, you do not need to fill out this form.
HELP
Please fill out this application honestly and completely. Please print.
1. HEAD OF HOUSEHOLD
(Parent or Caregiver)
Last Name
First Name
MI
Are you pregnant?
Yes, Due Date
No
If you are applying because you are pregnant, you need to give us a written statement from your doctor or health care provider saying you are pregnant and
giving your expected date of delivery. Use the space on the back of this form or give us a separate statement.
Home Address
Apt. or Lot #
MS
City
County
State
Zip Code
Home Telephone No.
Work Telephone No.
Mailing Address (if different)
MS
City
State
Zip Code
2. HOUSEHOLD MEMBERS
(List everyone in your household, starting with yourself first.) Attach proof of age for your children you are applying for, such as a copy of birth certificate(s).
Are you
Social Security
How is this
Date
US
Number
person related
Citizen?
of
Full Name
Sex
Race
Pregnant?
(for all applying)
to you?
(for all
Birth
person?
applying)
Yes No
Yes No Yes No
SELF
M
M
M
M
M
M
M
You must give us the Social Security # for any person who wants to be eligible for health benefits. The State will use the SSN to verify information such as income and
insurance coverage and to help maintain files regarding eligibility. The SSN may be used to match with records in other agencies, such as the Social Security Administration,
Internal Revenue Service, and Employment Security. If you mark “No” to U.S. Citizen, alien status for those applying must be verified to determine qualified alien status.
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Parent category: Medical