Medicaid And Kid Care Chip Renewal Form Page 3

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3
These are the people in your household who need to renew now
Tell us about anybody else in your household or on your tax return.
Person 1:
Name (first, middle, last & suffix):
This person's Social Security number is
On file
Not on file
If this person is no longer living in the household, check here
If not on file, write the Social Security number if this person is applying
Date of birth (month/day / year):
_ _ _ – _ _ – _ _ _ _
for health insurance coverage:
This person is:
Male
Female
This person may choose not to give the Social Security number if
he or she is not applying, but it helps us to have it.
How is this person related to you?
If this person has Medicaid, check here
.
If this person does not have Medicaid and wants health insurance coverage, check here
and fill out Attachment A on page 9.
Person 2:
Name (first, middle, last & suffix):
This person's Social Security number is
On file
Not on file
If this person is no longer living in the household, check here
If not on file, write the Social Security number if this person is applying
/
/
Date of birth (month/day / year):
_ _ _ – _ _ – _ _ _ _
for health insurance coverage:
This person is:
Male
Female
This person may choose not to give the Social Security number if
he or she is not applying, but it helps us to have it.
How is this person related to you?
If this person has Medicaid, check here
.
If this person does not have Medicaid and wants health insurance coverage, check here
and fill out Attachment A on page 9.
Person 3 :
Name (first, middle, last & suffix):
This person's Social Security number is
On file
Not on file
If this person is no longer living in the household, check here
If not on file, write the Social Security number if this person is applying
Date of birth (month/day / year):
_ _ _ – _ _ – _ _ _ _
for health insurance coverage:
This person is:
Male
Female
This person may choose not to give the Social Security number if
he or she is not applying, but it helps us to have it.
How is this person related to you?
If this person has Medicaid, check here
.
If this person does not have Medicaid and wants health insurance coverage, check here
and fill out Attachment A on page 9.
Person 4 :
Name (first, middle, last & suffix):
This person's Social Security number is
On file
Not on file
If this person is no longer living in the household, check here
If not on file, write the Social Security number if this person is applying
Date of birth (month/day / year):
_ _ _ – _ _ – _ _ _ _
for health insurance coverage:
This person is:
Male
Female
This person may choose not to give the Social Security number if
he or she is not applying, but it helps us to have it.
How is this person related to you?
If this person has Medicaid, check here
.
If this person does not have Medicaid and wants health insurance coverage, check here
and fill out Attachment A on page 9.
Person 5 :
Name (first, middle, last & suffix):
This person's Social Security number is
On file
Not on file
If this person is no longer living in the household, check here
If not on file, write the Social Security number if this person is applying
Date of birth (month/day / year):
_ _ _ – _ _ – _ _ _ _
for health insurance coverage:
This person is:
Male
Female
This person may choose not to give the Social Security number if
he or she is not applying, but it helps us to have it.
How is this person related to you?
If this person has Medicaid, check here
.
If this person does not have Medicaid and wants health insurance coverage, check here
and fill out Attachment A on page 9.
?
3
Questions?
Call our customer service center at 1-855-294-2127 (TTY/TDD: 1-855-329-5204).
The call is free. You can call 7:00 a.m. to 6:00 p.m. Monday to Friday. Or visit

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