Application For Health Care Assistance
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Application for Health Care Assistance
Name
Social security number
Mailing address
Home phone
(_______)
Town, state, and zip
Daytime phone (_______)
Town where you live
Directions to your home
Yes,
No
please include proof
Does the applicant have an authorized representative or legal guardian?
If yes, check one:
Authorized representative
Legal guardian
Name
Telephone
(_______)
Mailing address
Town, state, and zip
If legal guardian, name of probate court _________________________
Date appointed
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pays for medical expenses for children under 21, people with children, and people who are blind, have a
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disability, or who are age 65 or older.
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helps pay for medical services for children under age 18 and pregnant women.
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helps pay medical expenses for people age 18 and older who do not have
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insurance for both doctors and hospitals.
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blind, have a disability, or are age 65 or older.
helps people of any age.
If this is the only
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assistance your household is applying for, you only need to answer questions 1-2, 4-5, 8-9 and 17-24.
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help pay Medicare expenses.
Qualified Medicare Beneficiary (QMB)
pays Medicare
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premiums, deductibles and coinsurance.
Specified Low-Income Medicare Beneficiary (SLMB) and Qualified
Individuals (QI-1)
pay Part B premiums.
Qualified Disabled Working Individual (QDWI)
pays Part A premiums.
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these are the only assistance your household is applying for, you only need to answer questions 1-2, 4-5, 8-9 and 17- 24.
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(DCHC ~ Katie Beckett) pays for medical services for children with disabilities who
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are living at home and would be eligible for Medicaid if living in an institution. Parents’ income is not counted
when determining eligibility.
If this is the only program your household is applying for, you only need to answer
questions 1-2, 4, 8-11, 18, 20-21 and 24.
All health care programs have income limits; some also have resource limits. Some programs may have premiums or
copayments. Children who are members of federally designated American Indian or Alaska Native tribes may not have to
pay a Dr. Dynasaur premium.
**************************************************
If you do not speak English, we can provide free translation for our services.
Please tell us if you need an interpreter for any language.
Nu qu v c thc mc hoc cn cc dch v phiên
, :
dch, xin gi:
(Vietnamese)
(Russian)
Si vous avez des questions ou avez besoin de services
Ukoliko imate dodatnih pitanja ili Vam je potreban prevodilac,
de traduction, appelez le:
(French)
javite se na : (SerboCroatian)
People with a hearing impairment can call the statewide relay service at
1-800-253-0191 (TDD) or 1-800-253-0195 (voice)
HC 202MED R 01/10
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Parent category: Business