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

Tell Us If You Would Like Help With Child Support

The Child Support Agency can help get financial and medical help for the child from the child’s absent parent.

If you seek assistance from the Child Support Agency, the courts can establish paternity and establish and

enforce medical and financial support obligations.

There are other benefits to working with the Child Support Agency. For example, your child may be eligible for

other financial benefits, including Social Security, pension benefits, veteran’s benefits and possible inheritance.

Also, your child may benefit by having a bond between parent and child. Finally, your child may benefit by

getting important medical history information.

If you want the Child Support Agency’s help in establishing paternity or in getting a financial or medical support

order through the court, check the “Yes” box. If you check the box, someone will contact you.

Yes, I would like help from the Child Support Agency.

Voter Registration

ARE YOU REGISTERED TO VOTE IN NORTH CAROLINA?

Yes

Registering to vote is easy in North Carolina. State law requires voters to register 25 days before an

election. DSS can help you with registration paperwork. If you would like to register to vote in North

Carolina, ask your caseworker for a voter registration form, and if you need help, to assist you in completing

the form.

What Language Does the Family Prefer to Speak? (optional)

The federal government requires the State to provide information about the languages the family speaks.

Please help us by providing the information for the parent(s)/other adult(s) living in the home. (NOTE: You

may still apply for Health Check (Medicaid)/Health Choice even if you don’t answer the questions below.)

Name of person (first, middle initial, last)

Language person prefers to speak (circle one)

English

Spanish

Other (Specify_____________)

English

Spanish

Other (Specify_____________)

By signing this application, you are stating that you understand the following.

I attest that all statements recorded on this document are true and correct to the best of my knowledge.

I have either read or had read to me all attachments to this application, and I understand my rights and

responsibilities as an applicant/recipient.

I authorize the release of any information necessary to establish my family's eligibility. I understand that

this information may include medical information about the individuals applying for health coverage

and/or nonmedical information about individuals applying and others. This might include information

from doctors, hospitals, employers and insurance companies.

I authorize the copying of this release form to verify information. It shall remain valid and in force until

revoked by me in writing.

I have received or understand that I will receive a copy of the “Medicaid Notice of Privacy Practices.”

I understand that if Medicaid pays for nursing facility care, in-home care services, or services provided

under the Community Alternatives Program (CAP), Medicaid may become a creditor of my estate and

my estate may be subject to recovery to repay Medicaid.

Signature

(parent or other adult):

Date:

DMA-5063 (02-2012)

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

Page 6

Health Check Application Page 6

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