Dhhs Form 3400 - Application For Medicaid And Affordable Health Coverage Page 6
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16STEP 1: PERSON 2
Complete Step 1 for 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?
a. If you don’t have a SSN, have
3. Date of birth (mm/dd/yyyy)
4. Sex:
Male
Female
5. Social Security number (SSN)
you applied for one?
Yes
No
We need this if PERSON 2 wants health
6. Does PERSON 2 live at the same address as you?
Yes
No
If no, indicate the reason at
coverage and has an SSN.
question 16.
If no, list address:
7. Does Person 2 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 Person 2 file jointly with a spouse?
Yes
No If yes, name of spouse:
b. Will Person 2 claim any dependents on your tax return?
Yes
No
If yes, list dependents:
c. Will Person 2 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?
8. 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
9. Does PERSON 2 need health coverage? (Even if you have insurance, there might be a program with better coverage or lower costs)
YES. If yes, answer the questions below.
NO. If no, SKIP to the income questions on page 7. Leave the rest of this page blank.
10. Do you have a disabling physical, mental, or emotional health condition that causes limitations in activities?
Yes
No
11. Do you need to live in a medical facility or nursing home or need nursing services at home?
Yes
No
12. 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
13. Does PERSON 2 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.
14. Is PERSON 2 a U.S. citizen or U.S. national?
Yes
No
15. If PERSON 2 isn’t a U.S. citizen or U.S. national, does PERSON 2 have eligible immigration status?
Yes
No
If YES, fill in PERSON 2’s document type and ID number below.
a. Immigration document type:
b. Document ID number:
c. Has PERSON 2 lived in the U.S. since 1996?
Yes
No
d. Is PERSON 2, their spouse or parent a veteran or an active-duty member of the U.S. military?
Yes
No
16. If you have not applied for a Social Security Number, list the reasons
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
17. Does PERSON 2 want help paying for medical bills from the last 3 months?
Yes
No
a. If YES, was this person’s household size the same during these 3 months as it is now?
Yes
No
b. Was this person’s 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: $
18. Does PERSON 2 live with at least one child under 19, and is PERSON 2 the main person taking care of this child?
Yes
No
19. Is PERSON 2 a full-time student?
Yes
No
20. Was PERSON 2 in foster care in South Carolina at age 18 or older?
Yes
No
21. Is PERSON 2 currently living in a foster home?
Yes
No
22. Is PERSON 2 currently living in a DJJ group home?
Yes
No
Now, tell us about any income from PERSON 2 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 6 of 13
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