Financial Eligibility Application Nc Dhhs 3014 Adap (Page 2 of 2) in pdf

INSTRUCTIONS

Purpose: To collect information required for the determination of program eligibility.

An interviewer completes this form when a service authorization is requested unless a current form is already on file. Once determined,

eligibility generally extends for 12 months. The exception is new applications received during the annual renewal periods for the HIV

Medication (January-March) and Kidney (April-June) programs. These may extend for up to 15 months. A new form is required when

changes in countable family members and/or income occur.

Preparation: Consult Purchase of Medical Care Services manual for information on residency requirements, income calculation and

expense documentation. Income may be entered in the column labeled "Gross Income" or the one labeled "Income After Taxes". The

same income should not be entered in both columns. Both Net and Gross Income need to be completed for ADAP.

Instructions for Completing Certain Items on this Form:

6. Select one of the following languages and enter the 2 letter code in block 6 on the front of this form.

Arabic (AR)

Gujarati (GU)

Miao (MI)

Serbo-Croatian (SC)

Cambodian (CA)

Hindi (HI)

Mon-Khmer (MK)

Spanish (SP)

Chinese (CH)

Hmong (HM)

Other (OT)

Tagalog (TA)

English (EN)

Hungarian (HU)

Persian (PE)

Thai (TH)

French (FR)

Italian (IT)

Poland (PO)

Urdu (UR)

French Creole (FC)

Japanese (JA)

Portuguese (PG)

Vietnamese (VI)

German (GE)

Korean (KO)

Portuguese Creole (PC)

Greek (GR)

Laotian (LA)

Russian (RU)

14. Countable family members are related to the applicant by blood, marriage or adoption, live in the same household and share a

financial responsibility.

16. Earned income must be documented if medical expense deductions exceed $3,000 or an inpatient stay is requested. Medical

expense deductions must be documented in full when they exceed $3,000.

18. Deductible medical expenses are those paid or incurred by a countable family member during the 12 months prior to the earliest

date of service. Expenses paid for by another party or requested for coverage by a program cannot be used as deductions. The

Cancer Program and ADAP are based on gross income and do not allow for deductions of any kind.

Submit this application and documentation as required to the following address: DHHS Office of the Controller, Purchase of Medical Care

Services, 1904 Mail Service Center, Raleigh NC 27699-1904.

Additional forms may be ordered by faxing a request to 919-733-0352 or calling 919-855-3672.

TERMS AND CONDITIONS FOR APPLICANT

I agree to notify the interviewer within 30 days about any changes in the patient’s address, financial resources, expenses, family

situation, or health insurance coverage that might affect his or her eligibility for Department payment programs. I certify that the

information I have provided is a true and complete statement of facts according to my best knowledge and belief. I understand that

information provided may be checked by a state reviewer, and I agree to provide the financial records required to carry out this

investigation. I also understand that my employer may be asked to verify information concerning my income.

I assign insurance benefits to the Department. I agree to repay the Department any money I receive from insurance or liability

settlements for services or appliances which the Department purchased for me. I understand that such payments should be made to the

Department within 45 days of the date that I receive them and that the amount paid to the Department should not exceed the amount

the Department paid the provider. I further agree that failure to repay assigned insurance benefits to the Department is a reason for denial

of future service requests to the Department until such amounts have been repaid.

I understand that my eligibility for Medicaid will be checked. I hereby authorize and agree to a free exchange of information

between the Division of Medical Assistance and the Department of Health and Human Services relating to financial information and the

amount of services provided by either program

I hereby authorize the interviewer and service providers to release to the Department and its affiliate programs the information

provided on this form and also the medical records of the patient which pertain to medical services or appliances for which reimbursement

is being sought from the Department.

I also authorize release of this information to the county health department where the patient resides and/or receives services.

I also authorize release of the information on this form to all health departments and hospitals in North Carolina. These disclosures shall

be made for purposes of determining the patient’s eligibility for Department payment programs and for conducting program evaluation.

I voluntarily give my consent to the terms of this release. My consent shall be valid for a period of one year. I further understand

that I may revoke my consent at any time. Such revocation does not affect the validity of my consent for information disclosed prior to

the revocation.

I understand that I may appeal the denial of this financial eligibility application. Information on how to appeal the denial can be

obtained by writing to the N.C. DHHS Office of the Controller, Purchase of Medical Care Services, 1904 Mail Service Center, Raleigh NC

27699-1904. I understand that payment by the Department for health care provided to the patient is dependent upon the patient meeting

all financial and medical requirements, timely submission of authorization requests and claims, and the availability of funds.

WEBSITE:

DHHS 3014-ADAP (Revised 10/07)

Purchase of Medical Care Services (Review 10/10)

Financial Eligibility Application Nc Dhhs 3014 Adap Page 2

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