Medicaid And Kid Care Chip Renewal Form Page 8
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12Read and sign this application
Renewal of coverage in future years
Read the statement below and check one box.
To make it easier to check my income at renewal time, I give permission to the [state agency] to use income
information from my tax returns for the number of years I checked below.
I understand that the [state agency] will send me a letter with the income information they have. I can make
changes to it. I can also change my mind and not allow the [state agency] to check this information.
Yes, I give permission to check my income on tax returns for (check one box):
5 years (the longest time)
4 years
3 years
2 years
1 year
No, I do not give permission to use my tax returns.
Your rights and responsibilities
Read the statements below.
I am signing this renewal form under penalty of perjury. That
I
If I think Wyoming Medicaid or Kid Care CHIP has made a mistake,
means that I have provided true answers to all the questions on
can appeal its decision. To appeal means to tell someone at the
Wyoming Department of Health that I think the action is wrong, and
this form to the best of my knowledge, and I know that I may be
ask
subject to penalties under federal law if I provide false or untrue
for a fair review of the action. I know that I can find out how to appea
l by
information.
contacting Customer Service Center at 1-855-294-2127. Someone
from
the Customer Service Center will explain anything about this applica
tion
to me if I need that.
I must tell the Wyoming Department of Health if anything
changes and is different from what I wrote on this form. I can call the
Customer Service Center at 1-855-294-2127 or visit
I understand that if I do not qualify for Medicaid or Kid Care CHIP,
to report any changes. I understand that a
the Wyoming Department of Health may send my information to
change in my information might affect whether someone in my
another program so they can see if I qualify.
household qualifies for coverage.
I know that under federal law, discrimination is not permitted
on the basis of race, color, national origin, sex, age, sexual
orientation, gender identity, or disability. I can file a
complaint of discrimination by visiting
hhs.gov/ocr/office/file.
Sign and date below. If you want an authorized representative or want to change the authorized
representative you have now, fill out Attachment C on page 11.
If you are an authorized representative, check here
, sign below, and fill out Attachment C on page 11.
Signature of household contact or authorized representative:
Date:
?
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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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