Dhhs Form 3400 - Application For Medicaid And Affordable Health Coverage Page 13
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166. I know that I must tell SCDHHS within 10 days if any information I listed on this application changes and is different than
what I wrote on this application. I understand that a change in my information could affect the eligibility for member(s) of my
household.
7. The information I provide on this application and in future interaction with SCDHHS will be used to check my eligibility for
help paying for health coverage, if I choose to apply. If the information I provide doesn’t match electronic data, I may be
asked to send proof. I know that, unless I specifically ask to be excluded, information collected will be securely stored in
order to be sure that services provided to my family and me are sufficient and necessary.
8. If I think SCDHHS, the agency that administers Healthy Connections, the state’s Medicaid program, has made an error I can
appeal its decision. To appeal means to tell someone at SCDHHS that I think the action is wrong, and ask for a fair hearing.
I must submit a written request for such a hearing to SCDHHS. I know that I may represent myself or be represented by
someone other than myself.
9. I know that personal health information I provide or that is later gathered by SCDHHS is covered by the Health Insurance
Portability and Accountability Act of 1996 (HIPAA) and I will receive a Notice of Privacy Practices along with my Healthy
Connections Card(s).
Does any child on this application have a parent living outside of the home?
Yes
No
I confirm that no one applying for health insurance on this application is incarcerated (detained or jailed). If not,
is incarcerated.
Renewal of coverage in future years
To make it easier to determine my eligibility for help paying for health coverage in future years, I agree to allow Medicaid or the
Health Insurance Marketplace to use income data, including information from tax returns. Medicaid will send me a notice, let
me make any changes, and I can opt out at any time.
Yes, renew my eligibility automatically for the next:
5 years (the maximum number of years allowed), or for a shorter number of years:
4 years
3 years
2 years
1 year
Don’t use information from tax returns to renew my coverage.
Sign this application.
The person who filled out Step 1 should sign this application. If you’re an authorized representative, you
may sign here, as long as you have provided the information required on DHHS Form 1282 - Authorized Representative.
By signing, I state that I have read and agree to the rights and responsibilities stated on this application.
Signature
Date (mm/dd/yyyy)
Please print this form, then sign it on the line above before submitting.
STEP 5
Mail the completed application.
SCDHHS - Central Mail
If you want to register to vote, you
Mail your signed application to:
PO Box 100101
can complete a voter registration
Columbia SC 29202-3101
form at .
NEED HELP WITH YOUR APPLICATION?
SCDHHS.gov
or call us at 1-888-549-0820. Para obtener una copia de este formulario
Visit
en Español, llame 1-888-549-0820. If you need help in a language other than English, call 1-888-549-0820 and tell the customer service
representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-888-842-3620.
DHHS Form 3400 (June 2016)
Application for Medicaid and Affordable Health Coverage
Page 13 of 13
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