Form Dma-5007mr - Redetermination For Aged, Blind, And Disabled Adult Categories And/or Family Planning Waiver Services - 2007 Page 3

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Read Each Statement Below and Sign at the Bottom of the Next Page.

What are My Rights?

You have the right to:

You have the right to a hearing if:

•

Apply for assistance, and, if found not eligible, reapply at

Your assistance was terminated and you believe the

any time.

decision is not correct.

•

Have any person, not to exceed 3, participate in the

You believe your assistance is incorrect based on the

interview for redetermination of eligibility.

county's interpretation of State regulations.

•

Have any information given to the agency kept in

Your request for a review of your circumstances was

confidence.

delayed beyond 30 days or rejected.

•

Receive assistance, if found eligible.

The N.C. Department of Health and Human Services

•

Be informed of information needed to determine

does not discriminate on the basis of race, color, national

origin, sex, religion, age or disability in employment or

continuing Medical eligibility

the provision of services

What are My Responsibilities?

□

I agree to let my income maintenance caseworker know within 10 days following any change in my situation. I will notify my income maintenance

caseworker concerning any change in address, employment, property, resources, expenses or needs, living arrangements or number in the family or at any

other time when I am in doubt whether a particular change in circumstances should be reported. In addition, I will notify my income maintenance caseworker

immediately when the amount of my assistance is greater than the amount to which I am entitled.

□

I understand that it is against the law to willfully withhold information or make false statements and that I am subject to prosecution if I do. I certify that the

information I have provided (concerning my situation or that of the person(s) for whom I am making application) is a true and complete statement of facts

according to my best knowledge and belief. I understand that all statements will be thoroughly investigated by the county department of social services. I

understand that a State or Federal reviewer may check the information on this form, and I agree to this investigation and understand that I must cooperate

with the reviewer. I understand I must provide the county department of social services as well as State and Federal officials, upon request, the information

necessary to determine eligibility. I further agree that my medical and financial records may be made available to the agency and the State. I understand

that the information provided may be stored in a computer Data Bank. I have received, or will receive, a copy of the “Medicaid Notice of Privacy Practices.”

□

I understand that any Medicaid ID card I receive is to be used only for the persons listed on the ID card. I understand that it is against the law to give my ID

card to someone whose name is not listed on it and that I may be prosecuted for fraud if I let someone else use my ID card.

□

I understand that if any resources (including the homesite, other real property, cash, bank accounts, and other investments) are transferred out of the

recipient’s name without receiving fair market value for the resources, it could result in a period of ineligibility for long term medical care, such as in a nursing

facility, or for in-home care. I have reported all resource transfers when completing this review of my eligibility and will report any new transfers to my worker

within 10 days.

□

I understand I must furnish all social security numbers used by me and/or anyone listed on this application to determine my/our eligibility for assistance. I

understand these social security numbers will be used in matching information with the Social Security Administration (SSA), Internal Revenue Service

(IRS), Employment Security Commission (ESC), out-of-state welfare and ESC agencies, and any other agencies, when applicable. If I do not want these

social security numbers used in the matches, I understand I have the right to withdraw my application or have my assistance terminated.

□

I understand that by accepting Medical Assistance under any aid/program category, I agree to give back to the State any and all money that is received by

me or anyone listed on this application from any insurance company for payment of medical and/or hospital bills for which the Medical Assistance program

has or will make payment. In addition, I agree that all medical payments or medical support paid or owed due to a court order for me or anyone listed on this

application must be sent to the State to repay past or current medical expenses paid by the State. This includes insurance settlements resulting from an

accident. I further agree to notify the county department of social services if I or anyone listed on this application is involved in any accident.

□

I understand that this assignment of rights continues as long as I or anyone listed on this application receive Medicaid or any cash assistance program and

is based on Federal regulations (42 CFR 433.147-148).

□

Any child or spousal support (money) which is paid directly to me must be reported to the county department of social services and will be counted as

income when determining eligibility for Medicaid benefits and/or the amount of any cash assistance check.

□

I understand that North Carolina must be named remainder beneficiary for annuities purchased after a certain date. Contact the county DSS for more

information.

□

I understand that if Medicaid pays for certain medical services, Medicaid may become a creditor of my estate and my estate may be subject to recovery to

repay Medicaid. Ask your Medicaid case worker for specific information regarding which services are applicable to estate recovery.

□

I hereby certify under penalty of perjury, that I and all of the persons for whom I am requesting assistance are living in North Carolina with the intention of

remaining permanently or for an indefinite period.

□

I have received an explanation of family planning services, health screening for adults, and other services available through the department of social

services.

□

I certify that I and all of the persons for whom I am requesting assistance, with the exception of assistance with Emergency Medicaid services, are U.S.

citizens or have eligible immigration status. Persons applying for Emergency Medicaid services only are not required to provide documentation of

citizenship status.

DMA-5007MR 12-07