South Carolina Department Of Health And Human Services Medical Support Referral For Low Income Families

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South Carolina Department of Health and Human Services

MEDICAL SUPPORT REFERRAL FOR LOW INCOME FAMILIES (LIF) CASES

Must be completed in ink

Agency Use Only

Family Number:

Medicaid ID Number:

County:

Date Referred to Child Support Enforcement:

If Good Cause has been determined, attach the verification and documentation to the DHHS Form 2700 and file in the case record.

Name: (Last, First, MI)

Social Security No:

Sex:

Relationship to Children:

Race:

Date of Birth:

White

Black

Hispanic

Asian

Other:

Street Address:

Mailing Address:

City:

State:

Zip Code:

City:

State:

Zip Code:

Name/Address of Your Employer:

Shift:

Home Telephone No:

Work Telephone No:

(

)

(

)

Do you have an attorney actively engaged in child support action?

Yes

(If Yes, attach release.)

Current Marital Status:

Married

Divorced

Common Law

Other

Spouse’s Name:

Place of Marriage:

Marriage Date:

Divorce Date:

Child’s Name:

Child’s Sex:

Child’s Medicaid ID No:

Child’s SS Number:

Child’s Birth

Child’s Birthplace:

Paternity Legally

Date:

Verified?

Yes

If Married, Date of Marriage:

Relationship of children’s parents at time of birth:

Married

Divorced

Common Law

Other

Place of Marriage (City/State):

Name (Last, First, MI)

Alias/Nickname:

Social Security No:

Mailing Address:

City:

State:

Zip Code:

Is address current?

If No, date last lived there:

Yes

Street Address:

City:

State:

Zip Code:

Is address current?

If No, date last lived there:

Yes

Previous Address:

City:

State:

Zip Code:

Home Telephone No:

Work Telephone No:

(

)

(

)

Date of Birth:

Birthplace:

Driver’s License No:

Expiration Date:

Current Marital Status:

Race:

White

Black

Weight:

Height:

Hair Color:

Eye Color:

Identifying Marks:

Sex:

Hispanic

Asian

lbs

Other:

Last Known Employer’s Address/Telephone No: (

)

Date Last Worked:

Monthly Salary:

Father’s Name & Address/Telephone No: (

)

Mother’s Name & Address/Telephone No: (

)

Name/Address of Last School Attended:

Police Record?

Date of

Place: (City/State)

Offense:

Location of Incarceration:

Release Date:

Yes

Arrest::

Usual Occupation:

Served in Armed Forces:

Branch:

Entry Date:

Discharge Date:

Yes

Are payments made to you or through the courts ?

To me or

Through the courts

Do you receive child support?

Yes

If other, explain:

(Circle the correct answer. )

Date last payment

Child’s Name

Amount

Voluntary?

Court-ordered?

How often paid?

Amount overdue?

was received?

Yes

If Court-ordered, Docket Number:

Name/Address of Court:

If any answer above is unknown, the information is truly not known and I have no way of finding out the information.

I give the above information as truthful and correct to the best of my knowledge for the purpose of receiving Medicaid and will be used in court against the absent parent.

Signature of Custodial Parent/Applicant

Date:

Signature of Medicaid Eligibility Worker:

Date:

DHHS Form 2700 ME Low Income Families Only (September 2007)