Applicant/recipient Claim For Hardship Exemption - Maryland Division Of Eligibility Waiver Services

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EMPLOYED INDIVIDUALS WITH DISABILITIES (EID) PROGRAM
APPLICANT/RECIPIENT CLAIM FOR HARDSHIP EXEMPTION
Division of Eligibility Waiver Services (DEWS)
Schaefer Tower
6 St. Paul Street, Suite 400
Baltimore, Maryland 21202
Date__________________
MA No._______________
Name____________________________
Address__________________________
_________________________________
Dear Division of Eligibility Waiver Services Case Manager,
I, ________________________________ am requesting a review of my case for a “Claim
of Hardship” (COMAR 10.09.41.07C.) for the exemption of paying my premium of
$____________ for Medical Assistance (Medicaid) benefits under the Employed
Individuals with Disabilities (EID) Program.
The reason I am requesting this is because:
(Please specifying the underlying circumstances payment of the enrollment fee would
compromise your ability to obtain and provide basic food, shelter, and clothing. You may
attach additional pages if needed.)
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
_________________________________________________________________________
DHMH EID 2A Claim for Hardship Exemption
Page 1 of 2
04/15/13

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