Application For Retroactive Medicaid Coverage - Department Of Human Services - Case Records Management Unit Form

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Application for Retroactive Medicaid Coverage
If you and/or a household member requests retroactive Medicaid coverage to pay for medical bills from the
past 3 months, please complete, sign and return this application form. This form will be used to determine
if you and or a household member qualifies for retroactive Medicaid coverage. You and/or a household
member must meet all eligibility requirements for Medicaid during the retroactive period to qualify for
Retroactive Medicaid coverage.
How to submit
Mail:
Department of Human Services
Case Records Management Unit
this retroactive
th
441 4
Street, NW, Suite 1C-15
Medicaid
Washington, DC 20001
coverage
application
Medicaid@dc.gov
Email:
Fax: (202) 535-1122
In Person:
Take this completed and signed form to one of the Service Centers listed
below. If you have any questions, please Call DC Health Link Customer
Service at
(855) 532-5465/TTY (855) 532-5465.
ESA Service Centers: You may drop off the completed and signed
form at any of the below service centers.
H Street Service Center
Congress Heights Service Center
609 H Street, NE
4001 South Capitol Street, SW
Washington, DC 20002
Washington, DC 20032
Fort Davis Service Center
Anacostia Service Center
3851 Alabama Avenue, SE
2100 Martin Luther King Avenue, SE
Washington, DC 20020
Washington, DC 20020
Taylor Street Service Center
1207 Taylor Street, NW
Washington, DC 20011
1
D.C. Application for Retroactive Medicaid Coverage (3/2014)

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