Medicaid And Kid Care Chip Renewal Form Page 9

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People applying for the first time
Attachment A
To help you fill out Section 3, page 3
Tell us about anyone in your household who wants to apply for Medicaid. Do not answer these question for people
who already have Medicaid or Kid Care CHIP. If more than two people are applying, make a copy of this page.
Name of person applying:
Name (first, middle, last & suffix)
Tell us about citizenship
Is this person a U.S. citizen or U.S. national?
Yes If yes, go to "Tell us more information about this person"
No If no, answer all of the questions below.
If this person has eligible immigration status, check here
and fill in the document type:
and
ID number:
See Attachment D on page 12 for more information about eligible immigration status and document types.
.
If this person has lived in the U.S. since 1996, check here
If this person, his or her spouse, or a parent is a veteran or an active duty member in the U.S. military, check here
Tell us more information about this person
If this person lives with at least one child under the age of 18, and is the main person taking care of this child, check here
If this person is 18 years or younger and has a parent living outside of the household, check here
If this person wants help paying for medical bills from the last three months, check here
.
Tell us about race and ethnicity. You may choose not to answer these questions.
If this person is Hispanic/Latino,
What is this person’s race? Check all that apply:
check all that apply:
White
Asian Indian
Korean
Guamanian or Chamorro
Vietnamese
Samoan
Chinese
Mexican
Mexican American
Black or African
American
Other Asian
Other Pacific Islander
Filipino
Chicano/a
Puerto Rican
Native Hawaiian
Other
American Indian or
Japanese
Cuban
Other
Alaska Native
?
9
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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