Form Dma-5007mr - Redetermination For Aged, Blind, And Disabled Adult Categories And/or Family Planning Waiver Services - 2007 Page 4

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SERVICES
Please check the block if you need any of the services listed below or if you would simply like to have
additional information.
MEDICAID TRANSPORTATION: Assistance with arranging or providing transportation to
Medicaid covered services.
FAMILY PLANNING: Counseling and birth control for men and women of child-bearing age.
EPSDT/HEALTH CHECK: A service to insure that children and teens (birth to age 21) get regular
medical checkups and shots they need.
LIFELINE/LINK-UP ASSISTANCE PROGRAM: Lifeline Assistance allows a credit each month
on a local telephone bill. The Link-up program provides a 50% discount, up to $30.00 off the price of a
telephone hook-up.
WIC: Nutrition program for pregnant women and children up to age five.
VOTER REGISTRATION: You may now register to vote or update your voter registration record
while applying for benefits, redetermining eligibility, or reporting a change in address. I understand a
face-to-face interview is required to register to vote or update voter registration. Questions regarding
voter registration are answered by the Board of Elections.
READ, SIGN, AND DATE HERE
Recipient Certification
I hereby certify that the statements on this review form and any attachments to it are true and correct to the
best of my knowledge and belief.
___________________________________________________
______________________________
Signature
Date Signed
Please sign your name or make your mark and ask someone else to sign their name below as witness to your mark.
Representative or Witness:
_____________________________________Relationship:__________________
Signature
DMA-5007MR 12-07
4

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