Tell Us About Yourself and Any Household Members
1
Applying for Retroactive Medicaid Coverage
We will use this information to contact you, if needed.
Your Name (first, middle, last)
Social Security Number or DC Medicaid Number
Date of Birth (mm/dd/yyyy)
Home address (Check here if you are homeless)
City
State
ZIP code
Phone number (if you have one) ___________________________ Email address (if you have one) ___________________________
Yes No
Are you applying for retroactive coverage for yourself?
If additional household members are applying for Retroactive Coverage, please list them here. Tell us the name (first and last),
Social Security Number (SSN) or Medicaid ID#, and Date of Birth (DOB) of those household members.
Name______________________________________________ SSN or DC Medicaid ID#____________________ DOB __________________
Name______________________________________________ SSN or DC Medicaid ID#____________________ DOB __________________
Name______________________________________________ SSN or DC Medicaid ID#____________________ DOB __________________
2
Residence History
Did you or the household member(s) applying for retroactive coverage live in D.C. throughout the last 3 months?
Yes
No
If no, please tell us which household member(s) did not live in D.C., the state where they used to live, and which month they
moved into the District.
Name (first and last)
State
Month
(MM/YYYY)
___________________________________________________
______________________
____________________
Name (first and last)
State
Month (MM/YYYY)
___________________________________________________
______________________
____________________
Name (first and last)
State
Month (MM/YYYY)
___________________________________________________
______________________
____________________
3
Citizenship/Eligible Immigration Status* Information
Did you or the household member(s) applying for retroactive coverage have a change in U.S. citizenship/eligible immigration
status in the last three months?
Yes
No
If yes, please tell us the name of the person(s) whose citizenship/eligible immigration status has changed in the last three months
and the month the person became a U.S. citizen or met one of the eligible immigration status categories.
Name (first and last) ________________________________________________ Month (MM/YYYY) ____________________
Name (first and last) ________________________________________________ Month (MM/YYYY) ____________________
Name (first and last) ________________________________________________ Month (MM/YYYY) ____________________
*Please see Attachment B for more information on what is an eligible immigration status for Medicaid.
2
D.C. Application for Retroactive Medicaid Coverage (3/2014)
1
2
3
4
5
Form Op-305 - Application For Tax Amnesty - Connecticut Department Of Revenue Services, 2002
Financial
Form Dhs 1240 - Application For Financial And Snap Assistance - Hawaii Department Of Human Services
Legal
