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RIGHTS AND RESPONSIBILITIES

I UNDERSTAND THAT I MUST REPORT ANY CHANGES THAT OCCUR IN MY SITUATION TO THE DEPARTMENT OF SOCIAL SERVICES WITHIN TEN DAYS. I AGREE

TO ASSIGN MY RIGHTS TO MEDICAL SUPPORT AND OTHER THIRD-PARTY PAYMENTS TO THE DEPARTMENT OF MEDICAL ASSISTANCE SERVICES, EFFECTIVE

WITH MY COVERAGE UNDER MEDICAID. ALL MONEY I RECEIVE FOR (1) DIAGNOSIS OR TREATMENT OF ANY INJURY, DISEASE OR DISABILITY OR (2) MEDICAL

CARE SUPPORT MUST BE SENT TO THE DEPARTMENT OF MEDICAL ASSISTANCE SERVICES, THIRD PARTY LIABILITY SECTION. I UNDERSTAND REFUSAL TO

ASSIGN MY RIGHTS WILL MAKE ME INELIGIBLE FOR MEDICAID.

I UNDERSTAND THAT I HAVE THE RIGHT TO FILE A COMPLAINT IF I FEEL I HAVE BEEN DISCRIMINATED AGAINST BECAUSE OF RACE, COLOR, NATIONAL ORIGIN,

SEX, AGE, HANDICAP, OR RELIGIOUS BELIEF. I UNDERSTAND THAT I HAVE THE RIGHT TO APPEAL AND HAVE A FAIR HEARING IF I AM (1) NOT NOTIFIED IN

WRITING OF THE DECISION REGARDING MY APPLICATION WITHIN 45 DAYS; (2) DENIED MEDICAID; OR (3) DISSATISFIED WITH ANY OTHER DECISION THAT

AFFECTS MY RECEIPT OF MEDICAID. I UNDERSTAND THAT REFUSAL TO COOPERATE WITH A REVIEW OF MY MEDICAID ELIGIBILITY BY QUALITY CONTROL WILL

MAKE ME INELIGIBLE FOR MEDICAID UNTIL I COOPERATE WITH THE REVIEW.

I AUTHORIZE THE DEPARTMENT OF SOCIAL SERVICES AND THE DEPARTMENT OF MEDICAL ASSISTANCE TO OBTAIN ANY VERIFICATIONS NECESSARY TO

ESTABLISH MY ELIGIBILITY FOR ASSISTANCE. I AUTHORIZE RELEASE TO THE DEPARTMENT OF MEDICAL ASSISTANCE SERVICES ANY INFORMATION IN ANY

MEDICAL RECORDS PERTAINING TO ANY SERVICES RECEIVED BY ME AS A BENEFIT UNDER MY MEDICAL ASSISTANCE (MEDICAID) ELIGIBILITY.

I RECEIVED THE BOOKLETS:

MEDICAID HANDBOOK

[

] YES

[

] NO

BENEFIT PROGRAMS

[

] YES

[

] NO

I FILLED IN THIS FORM MYSELF.

[

] YES

[

] NO

IF NO, IT WAS READ BACK TO ME WHEN COMPLETED.

[

] YES

[

] NO

I DECLARE THAT ALL INFORMATION I HAVE GIVEN ON THIS APPLICATION IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF. I UNDERSTAND

THAT IF I GIVE FALSE INFORMATION, WITHHOLD INFORMATION, OR FAIL TO REPORT A CHANGE PROMPTLY OR ON PURPOSE, I MAY BE BREAKING THE LAW AND

COULD BE PROSECUTED FOR PERJURY, LARCENY, AND/OR WELFARE FRAUD. I UNDERSTAND THAT MY SIGNATURE ON THIS APPLICATION CERTIFIES, UNDER

PENALTY OF PERJURY, THAT I AM A U.S. CITIZEN OR ALIEN IN LAWFUL IMMIGRATION STATUS.

SIGNATURE OR MARK: __________________________________________________________________________________ DATE: _______________________________

WITNESS/AUTHORIZED

REPRESENTATIVE:_______________________________________________________________________________________DATE:________________________________

I COMPLETED THIS APPLICATION/REDETERMINATION FOR _________________________________________________. I UNDERSTAND THAT IF I AIDED OR ABETTED

THIS INDIVIDUAL IN OBTAINING ASSISTANCE FOR WHICH HE IS NOT ELIGIBLE, THAT I MAY BE BREAKING THE LAW AND COULD BE PROSECUTED.

SIGNATURE: __________________________________________________________________ RELATIONSHIP: ________________________ DATE: _________________

ADDRESS: _____________________________________________________________________________________________ TELEPHONE#: ________________________

VOTER REGISTRATION

CHECK ONE OF THE FOLLOWING:

( )

I AM NOT REGISTERED TO VOTE WHERE I CURRENTLY LIVE NOW, AND I WOULD LIKE TO REGISTER TO VOTE HERE TODAY. I CERTIFY THAT A VOTER

REGISTRATION FORM WAS GIVEN TO ME TO COMPLETE. (IF YOU WOULD LIKE HELP IN FILLING OUT THE VOTER REGISTRATION, WE WILL HELP YOU.

THE DECISION TO HELP YOU IS YOURS. YOU ALSO HAVE THE RIGHT TO COMPLETE YOUR FORM IN PRIVATE.)

( )

I AM REGISTERED TO VOTE AT MY CURRENT ADDRESS. (IF ALREADY REGISTERED AT YOUR CURRENT ADDRESS, YOU ARE NOT ELIGIBLE TO

( )

I DO NOT WANT TO APPLY TO REGISTER TO VOTE.

( )

I DO WANT TO APPLY TO REGISTER TO VOTE. PLEASE SEND ME A VOTER REGISTRATION FORM.

APPLYING TO REGISTER OR DECLINING TO REGISTER TO VOTE WILL NOT AFFECT THE ASSISTANCE OR SERVICES THAT YOU WILL BE PROVIDED BY THIS

AGENCY. A DECISION NOT TO APPLY TO REGISTER TO VOTE WILL REMAIN CONFIDENTIAL. A DECISION TO APPLY TO REGISTER TO VOTE AND THE OFFICE

WHERE YOUR APPLICATION WAS SUBMITTED WILL ALSO REMAIN CONFIDENTIAL AND MAY ONLY BE USED FOR VOTER REGISTRATION PURPOSES. IF YOU

BELIEVE THAT SOMEONE HAS INTERFERED WITH YOUR RIGHT TO REGISTER OR TO DECLINE TO REGISTER TO VOTE, YOUR RIGHT TO PRIVACY IN DECIDING

WHETHER TO REGISTER TO VOTE, OR YOUR RIGHT IN APPLYING TO REGISTER TO VOTE, YOU MAY FILE A COMPLAINT WITH: SECRETARY OF VIRGINIA STATE

BOARD OF ELECTIONS, NINTH STREET OFFICE BUILDING, 200 NORTH NINTH STREET, RICHMOND, VA 23219-3497. THE PHONE NUMBER IS (804) 786-6551.

***********************AGENCY USE ONLY **********************

ELEMENTS OF

MEETS ELIGIBILITY

EVALUATION

VERIFICATION/PERTINENT INFORMATION

REQUIREMENTS

VA RESIDENCY, IF QUESTIONABLE

_________________________________________________________

YES

RECEIVES SSI CHECK

SDX_______________SVES______________OTHER_____________

YES

If no, have the individual complete the Application for Benefits.

SSI CONDITIONAL/PRESUMPTIVE

_________________________________________________________

YES

ASSET TRANSFER

_________________________________________________________

YES

RESOURCES (IF HAS A TRUST OR

_________________________________________________________

OWNS UNDIVIDED HEIR PROPERTY,

CONTIGUOUS PROPERTY, FORMER

_________________________________________________________

HOME, OR OTHER REAL PROPERTY)

VALUE OF COUNTABLE RESOURCES

$_________________________________________________________

YES

RECOMMENDATION

CURRENT ELIGIBILITY:

ELIGIBLE: _______ EFFECTIVE DATE: ____________

INELIGIBLE_______

RETROACTIVE ELIGIBILITY:

ELIGIBLE: _______ EFFECTIVE DATE: ____________

INELIGIBLE_______

WORKER’S SIGNATURE; ____________________________________________________________________________ DATE: ___________________________

SUPERVISOR’S SIGNATURE: ________________________________________________________________________ DATE: ___________________________

ENROLLMENT

SPEC REVIEW: ______________________ CTY: ______________ Cl: ______________ BEGIN: _____________ END: ____________ TYPE: _____________

PD: 11 _______ 31 _______ 51 _______

APP DATE: __________________ MEDICAL RESOURCE: _______________ TYPE COV: ___________________

INS CO: _____________________________ POLICY NUMBER: ___________________ BEGIN DATE: ____________

END DATE: _____________

Application/redetermination For Medicaid For Ssi Recipients Template - Virginia Department Of Social Service - 2003 Page 2

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