Medical Renewal Form Page 2
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9Case name:
Case number:
Date of request:
Tell us about the people in your household
1. We show the following people as living in your house.
Name
Date of birth
Has this person
Wants medical
moved out?
benefits?
*
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Check yes if this person would like to renew or apply for medical benefits.
*
Yes
No
2. Has anyone moved into your house?
If yes, complete the section below.
List people who moved in only
:
Person 1: Name
(first, middle initial, last)
Date this person moved in:
This is my:
Sex:
husband or wife child
Female
step child other: ___________________
Male
City of birth:
State of birth:
Social Security number (SSN)
Date of birth
:
(month, day, year)
Are you applying for health coverage for this person?
Yes
No
If yes, you must tell us about citizenship and Social Security or
If you do not have a SSN check
Is this person a U.S. citizen?
immigration status:
Yes No
this box
If no, and this person has an Alien
Resident number, write it here:
Is this person Alaska Native or a member of a federally recognized American Indian tribe?
Yes No
Does this person receive services through Indian Health Services?
Yes No
Is this person the parent of a child who is living with you?
Yes No
Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Your answers to ethnicity and
Race
(choose one or more): American Indian or Alaska Native
race questions help us, but you
Asian
White
Black or African American
can choose not to answer them.
Native Hawaiian or other Pacific Islander
*Use another sheet of paper if you need to write about more people.
3. Have you moved in the last year? Yes
No, If yes, please complete below.
New home address:
City:
ZIP code:
New mailing address (if different):
City:
ZIP code:
?
?
Need help?
Please call your worker. The phone number is at the top of the first page.
Page 2
OHA 0945 (06/12)
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