Fillable Health Check Application (Page 3 of 6) in pdf

For Office Use Only

County DSS: _____________________

Date Received: ___________________

Case #: __________________________

Mail in

DSS

Health Dept

APPLICATION

Please complete. Then send pages 3-6 to your local department of social services. If you are an adult who has

no children living with you and you are applying for Medicaid, Medicaid for Pregnant Women or Family Planning

Services, begin with Question #2.

Tell Us About the Family

1. Who are all the children under age 21 who live in the home?

Fill out this information even for children who will not be applying for Health Check (Medicaid)/Health Choice. Social

Security number, proof of identity, and citizenship status are required only for those applying.

*Race

**Hispanic/Latino

Applying

(Use

Is Child

Date of

(Y, N)

Social Security

Name of child

for this

Sex

codes

a U.S.

birth

If yes, specify

Number

(first, middle initial, last)

child

(M, F)

below.

citizen?

(mo/day/yr)

using codes

(SSN)

(Y, N)

List all that

(Y, N)

below.

apply.)

*Asian= A American Indian or Alaska Native= I

Native Hawaiian or other Pacific Islander= P Caucasian or White= W

Black or African-American= B

** Hispanic Puerto Rican= P

Hispanic Cuban= C

Hispanic Mexican= M

Hispanic Other= H

2. Where do you & the children live?

(If different, please put your address on a separate sheet and return

with this application.)

Address:

Mailing Address (if different):

City:

State:

Zip Code:

City:

State:

Zip Code:

Home phone: (

)

Daytime phone: (

)

3. Who are the parents living with the children? If the children do not live with their parents, who are the adults

living in the home who care for the children?

**Hispanic/

*Race (Use

Latino

Children’s names and parent or adult

Name of parent or adult

Date of birth

Sex

codes in

(Y, N)

relationship to the children

(first, middle initial, last)

(mo/day/yr)

(M, F)

#1. List all

If yes, specify

(John – Mother, Mary - Stepmother)

that apply.)

using codes in

#1.

Anyone who applies for Medicaid, Medicaid for Pregnant Women, or Family Planning Services must provide their Social

Security numbers and may have to give information to the child support office

a. Do you want to apply for pregnancy coverage for any of the people listed in #3 above?

Yes

If you are applying for pregnancy assistance, you need to provide a statement from the doctor that includes the delivery

date and the number of babies expected. However, send in the application form even if you do not have the statement

from the doctor yet.

If yes, for whom?

Relationship to child(ren):

SSN

b. Do you want to apply for Medicaid for any of the people listed in #3 above? If you want to apply, you will be

contacted for information about bank accounts, personal property, stocks, bonds, etc. The total of these must be

less than $3,000. Also, if eligible, the person may be responsible for some medical bills.

Yes

If yes, for whom?

Relationship to child(ren):

SSN

c. Do you want to apply for family planning services for any people ages 19 and older listed above?

Yes

If yes, for whom?

Relationship to child(ren):

SSN

DMA-5063 (02-2012)

Questions about Health Check/ Health Choice? Call 1-800-662-7030.

Page 3

Health Check Application Page 3

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