Bhsf Form 2-L (Nf) - Medicaid Renewal Form For Nursing Home/group Home Care (Page 7 of 9) in pdf

Bhsf Form 2-L (Nf) - Medicaid Renewal Form For Nursing Home/group Home Care Page 7

BHSF Form VRD

Issued 07/21/11

AC/Office Name

Department of Health and Hospitals

Voter Registration Declaration (Optional)

If you fill it out, your answers will not affect the benefits you get from the

Louisiana Department of Health and Hospitals.

If you are not registered to vote where you live now, would you like to apply to register to vote here

today?

Yes

 If you checked “Yes,” please complete the attached form called the “Louisiana Mail Voter

Registration Application.” You may mail your completed Voter Registration Application to your

local Registrar of Voters listed on the application or mail it to the Department of Health and

Hospitals.

 IF YOU DO NOT CHECK EITHER BOX YOU WILL BE CONSIDERED TO HAVE DECIDED NOT

TO REGISTER TO VOTE AT THIS TIME.

Applying to register or declining to register to vote will not affect the amount of assistance that you will

be provided by this agency.

If you would like help in filling out the voter registration application form, we will help you. You may

call us toll-free at 1-888-342-6207. The decision whether to seek or accept help is yours. You may

fill out the application form in private.

If you choose to register to vote at this time, the information about the location where you completed

the application to register will remain confidential and will only be used for voter registration

purposes. If you choose not to register to vote, that information will also be kept confidential.

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 or in applying to register to vote, or your right to

choose your own political party or other political preference, you may file a complaint with:

Louisiana Secretary of State

Commissioner of Elections

P.O. Box 94125

Baton Rouge, LA 70804-9125

Phone: (toll-free) 1-800-883-2805

Print Your Name

Social Security Number

Date of Birth

Sign Your Name

Today’s Date

Bhsf Form 2-L (Nf) - Medicaid Renewal Form For Nursing Home/group Home Care Page 7