Dhhs Form 3400 - Application For Medicaid And Affordable Health Coverage Page 4
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16Complete Step 1 for each person in your family.
STEP 1: PERSON 1
Start with information about yourself.
Complete Step 1 for yourself, your spouse/partner and children who live with you and/or anyone on your same federal income
tax return if you file one. See page 2 for more information about whom to include. If you don’t file a tax return, remember to still
add family members who live with you.
1. First name, Middle name, Last name, & Suffix
2. Relationship to you?
SELF
3. Date of birth (mm/dd/yyyy)
4. Sex:
Male 5. Social Security number (SSN)
a. If you don’t have a SSN, have you applied for
one?
Yes
No If no, indicate the reason at
Female
question 15.
We need this if you want health coverage and have an SSN. Providing your SSN can be helpful if you don’t want health coverage since it can
speed up the application process. We use SSNs to check income and other information to see who’s eligible for help with health
coverage costs. If someone wants help getting an SSN, call 1-800-772-1213 or visit socialsecurity.gov. TTY users should call 1-888-842-3620.
6. Do you plan to file a federal income tax return NEXT YEAR?
(You can still apply for health insurance even if you don’t file a federal income tax return.)
YES. If yes, please answer questions a–c.
NO. If no, SKIP to question c.
a. Will you file jointly with a spouse?
Yes
No If yes, name of spouse:
b. Will you claim any dependents on your tax return?
Yes
No
If yes, list dependents:
c. Will you be claimed as a dependent on someone’s tax return?
Yes
No
If yes, please list the tax filer:
How are you related to the tax filer?
7. Are you pregnant or recently pregnant?
Yes
No If yes, a. How many babies are expected?
b. What is your due date?
c. If recently pregnant, enter the date the pregnancy ended:
d. Were you enrolled in Medicaid on the last day of pregnancy?
Yes
No
8. Do you need health coverage? (Even if you have insurance, there might be a program with better coverage or lower costs.)
YES. If yes, answer all the questions below.
NO. If no, SKIP to the income questions on page 5. Leave the rest of this page blank.
9. Do you have a disabling physical, mental, or emotional health condition that causes limitations in activities?
Yes
No
10. Do you need to live in a medical facility or nursing home or need nursing services at home?
Yes
No
11. Have you been diagnosed with and are receiving treatment for any of the following?
Yes
No
• Breast Cancer
• Cervical Cancer
• Atypical Breast Hyperplasia
• Precancerous Cervical Lesion (CIN 2/3)
12. Do you want to apply for Family Planning benefits?
Yes
No
Family Planning is a limited benefit program, which provides family planning services, family planning-related services and certain limited
preventative screenings. Family Planning is not full Medicaid coverage. If you leave this question blank, we will not assess you for Family Planning.
13. Are you a U.S. citizen or U.S. national?
Yes
No
14. If you aren’t a U.S. citizen or U.S. national, do you have eligible immigration status?
Yes
No
If YES, fill in your document type and ID number below.
a. Immigration document type:
b. Document ID number:
c. Have you lived in the U.S. since 1996?
Yes
No
d. Are you, or your spouse or parent a veteran or an active-duty member of the U.S. military?
Yes
No
15. If you have not applied for a Social Security Number, list the reason:
Issued for non-work reasons only No SSN due to religious reasons
Not eligible for SSN
Newborn, mother currently receiving Medicaid
Newborn, mother NOT receiving Medicaid
16. Do you want help paying for medical bills from the last 3 months?
Yes
No
a. If YES, was your household size the same during these 3 months as it is now?
Yes
No
b. Was your household income the same during these 3 months as it is now?
Yes
No
If NO, enter the total monthly income for: Last Month: $
2 Months Ago: $
3 Months Ago: $
17. Do you live with at least one child under the age of 19, and are you the main person taking care of this child?
Yes
No
18. Are you a full-time student?
Yes
No
19. Were you in foster care in South Carolina at age 18 or older?
Yes
No
20. Are you currently living in a foster home?
Yes
No
21. Are you currently living in a DJJ group home?
Yes
No
Now, tell us about any income from on the next page.
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 4 of 13
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