Healthcare Medicaid Application Form

HEALTHCARE MEDICAID APPLICATION FORM

Applicant Information

Social Security Number:     Date of Birth:

Female    Male    Other / Prefer not to say

Phone:     Email:

Relationship:     Phone:

Household Composition

List all persons who live with you, including yourself. Attach additional pages if necessary.

DOB:     Relationship:     Gross Monthly Income:

DOB:     Relationship:     Gross Monthly Income:

DOB:     Relationship:     Gross Monthly Income:

Income and Resources

Provide current sources of income and resources for the applicant and household. Report gross amounts before deductions.

Employed:    Employer Name:    Gross Monthly Pay:

Total Bank Accounts:    Vehicles (value):    Other Property (value):

Insurance and Medical Information

Do you currently have any health insurance?

Policy Number:    Group Number:    Subscriber Name:

Are you pregnant?    If yes, expected due date:

Do you consider yourself to have a disability?

Documentation Provided

Check all documents you are submitting with this application to establish identity, income, citizenship/immigration status, or medical need.

Government-issued photo ID     Social Security card or SSN verification

Pay stubs / Employer statement     Bank statements

Birth certificate / Citizenship document     Medical proof of pregnancy (if applicable)

Authorization and Certification

I certify, under penalty of law, that the information provided on this application and any supporting documentation is true, complete and correct to the best of my knowledge. I understand that knowingly making a false statement or misrepresenting information to obtain benefits may subject me to civil or criminal penalties.

I authorize the review and verification of any information provided on this application, including but not limited to employment, income, banking, tax, and benefit records, by the Medicaid program and its agents. I authorize the release of medical records and other relevant records necessary to determine eligibility for benefits. This authorization includes disclosure to federal and state agencies, health care providers, and third parties performing eligibility verifications.

I understand that I have the right to withdraw this application at any time prior to determination, but that information already used or verified may not be retrievable. I understand that this application does not guarantee immediate eligibility and that additional documentation or interviews may be requested.

Authorization expires on:

I acknowledge receipt of the privacy notice and understand how my protected health information may be used and disclosed for eligibility determination and care coordination. I consent to communications about my application by phone, mail, or electronic means unless I indicate otherwise.

Acknowledgment of Privacy Practices:    Consent to verify eligibility electronically:

Medical History Summary

Applicant Certification and Signature

By signing below, I certify that I am the applicant or an authorized representative signing on behalf of the applicant. I attest that I have read and understand the certifications, authorizations, and acknowledgments contained in this application.

If signed by an authorized representative, state relationship to applicant:

Warning: Any person who knowingly submits false statements or misrepresentations to obtain public benefits may be subject to civil or criminal penalties under applicable law. This application may be reviewed and verified with other agencies, employers, and financial institutions to establish eligibility. Retention of submitted documentation may be required for audit and compliance purposes.

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