Medicaid Citizen And Identity Tracking Log Form

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M
C
I
T
L
EDICAID
ITIZEN AND
DENTITY
RACKING
OG
Please see reverse for a more complete list of acceptable documents and their specific qualifying factors.
S
A
B
C
ECTION
SECTION
SECTION
R
I
OR
AND
ECIPIENT
NFORMATION
C
& I
C
I
ITIZEN
DENTITY
ITIZEN
DENTITY
C
urrent State Driver’s License or ID Card
U.S. Passport (Current or expired)
U.S. Birth Certificate
Last
Issuing State:________________________
Issuing State:__________________________
Name
Certificate of U.S. Citizenship (INS Form N-560
S
chool ID card (with photograph).
or N-561)
New Mexico Vital Statistics Agency Data
Match Record
First
Certificate of Naturalization (INS Form N-550 or
ID card issued by the Federal, State or local
N-570)
Final adoption decree
government.
Name
Issuing Entity:________________________
American Indian or Alaskan proof of Indian
A Certification of Birth Abroad (FS-545)
______/_______/_______
blood, certificate of degree of Indian blood, federal
DOB
Other (specify & see qualifying list on reverse)
A U. S. Citizen I.D. card (DHS Form I-197)
Indian census card or tribal membership card
____________________________________
Other (specify & see qualifying list on reverse)
______/_______/_______
SSN
C
U.S. Passport (Current or expired)
U.S. Birth Certificate
urrent State Driver’s License or ID Card
Last
Issuing State:__________________________
Issuing State:________________________
Certificate of U.S. Citizenship (INS Form N-560
Name
S
New Mexico Vital Statistics Agency Data
chool ID card (with photograph).
or N-561)
Match Record
Certificate of Naturalization (INS Form N-550 or
First
ID card issued by the Federal, State or local
Final adoption decree
N-570)
Name
government.
Issuing Entity:________________________
American Indian or Alaskan proof of Indian
A Certification of Birth Abroad (FS-545)
blood, certificate of degree of Indian blood, federal
______/_______/_______
DOB
Other (specify & see qualifying list on reverse)
A U. S. Citizen I.D. card (DHS Form I-197)
Indian census card or tribal membership card
Other (specify & see qualifying list on reverse)
SSN
______/_______/_______
____________________________________
C
U.S. Passport (Current or expired)
U.S. Birth Certificate
urrent State Driver’s License or ID Card
Last
Issuing State:__________________________
Issuing State:________________________
Certificate of U.S. Citizenship (INS Form N-560
Name
S
New Mexico Vital Statistics Agency Data
chool ID card (with photograph).
or N-561)
Match Record
First
Certificate of Naturalization (INS Form N-550 or
ID card issued by the Federal, State or local
N-570)
Final adoption decree
Name
government.
Issuing Entity:________________________
American Indian or Alaskan proof of Indian
A Certification of Birth Abroad (FS-545)
blood, certificate of degree of Indian blood, federal
______/_______/_______
DOB
Other (specify & see qualifying list on reverse)
A U. S. Citizen I.D. card (DHS Form I-197)
Indian census card or tribal membership card
Other (specify & see qualifying list on reverse)
______/_______/_______
SSN
____________________________________
PE Determiner/Agent of the State Signature:
Date:
Determiner/Agent Number:
PE Determiner Agency/Agent Location:
Determiner/Agent Contact E-mail:
Phone: (
)
My signature attests that I witnessed original documents as listed above. The witnessed documents are verified and attached.
MAD 398 Issued 10/10

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