Fillable Form Mdhs-Ea-901 Medi - Application (Page 3 of 4) in pdf

Has anyone applying for health benefits had any health insurance coverage in the past 6 months?

Yes

If the answer is yes, complete the following….

6. HEALTH INSURANCE INFORMATION

Insurance Company

End Date of

Policy Holder’s Name

Policy #

Name of Insured

or Employer Plan

Coverage

& Social Security #

7. Do you want to apply for health benefits for up to 3 months prior to the date of this application, if it is available?*

Yes

I f yes, which months?

(Attach proof of income for the month(s) that you need coverage, if different from what you told us in #3.)

*CHIP will not cover prior months.

8. Please tell us where you got this application

PRINT THIS FORM

10. RIGHTS AND RESPONSIBILITIES (Please read carefully.)

•

Children under 21 who are eligible for health benefits under Medicaid are eligible for free health check ups under a special

prevention program called Early and Periodic Screening, Diagnosis and Treatment (EPSDT). For more information, contact

your local Health Department or call 1-800-421-2408 and ask for EPSDT information.

•

Adults and children eligible for Medicaid must select a HealthMACS primary care provider or one will be chosen for you from a

list of participating doctors and clinics. Contact the Managed Care hotline at 1-800-627-8488 for more information.

•

Information about Family Planning Services and WIC food services is available from your local Health Department.

•

Information that you give is confidential. Your medical information can only be released if needed to administer the Medicaid or

CHIP Programs. If you receive care or treatment under Medicaid or CHIP, you authorize the health care provider to release to

Medicaid, DHS, and the CHIP insurer your medical records and information relating to your diagnosis, examination, and treatment.

•

Information that you give may be reviewed and verified by state and federal staff. You must fully cooperate with state and federal

workers if your case is reviewed. No additional permission is needed to get verification or other information.

•

Your application will be considered without regard to race, color, sex, age, handicap, religion, national origin, or political belief.

•

You may ask for a hearing if you are not satisfied with any action taken by the State of Mississippi in connection with your application

for health benefits.

•

Medicaid does not pay medical expenses that a third party, such as private health insurance, should pay. By accepting Medicaid,

you agree to give your rights to any third party payment to the Division of Medicaid. These payments include payments from

hospitals and health insurance policies.

•

You are encouraged to cooperate in identifying and locating any absent parent or help in establishing paternity for the children

applying unless you have good cause for not cooperating.

10.

10. Please sign this statement:

I certify that the information I have provided above is true to the best of my knowledge, and I give permission for the State of

Mississippi to make any necessary contacts to check my statements. I have read the list of my rights and responsibilities that is

printed above. I know that I could be penalized if I knowingly give false information. I certify that the children and adults I am

applying for are U.S. citizens or qualified aliens.

Signature of applicant

Date

MAIL THIS APPLICATION TO THE COUNTY DEPARTMENT OF HUMAN SERVICES OFFICE IN THE COUNTY WHERE

YOU LIVE. If you need help with this application, call your county DHS office or call 1-877-543-7669.

MDHS-EA-901 MEDI

Revised 05-16-00

Form Mdhs-Ea-901 Medi - Application Page 3

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