Georgia department of human services health coverage addendum

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Georgia Department of Human Services

Health Coverage Addendum

Please answer the following questions if you are applying for Health Coverage (Please complete all three pages of this form)

1. If you are an adult applying for Health Coverage for your dependent child(ren), do you want to receive Health Coverage for yourself? Yes No

2. Is anyone in the household pregnant? Yes No If yes, how many babies are expected during this pregnancy? ________

3. Is anyone applying for health coverage blind or disabled? Yes No If yes, please list___________________

4. Does anyone have other health insurance that covers anyone in your household? Yes No

5. If you answered yes to question 5 above, please complete the following information:

Name of Policy holder

Health Insurance Company Name, Address and Telephone Number

Type of Coverage

(Hospital, Medicare Supplement, Drugs,

Major Medical)

Name of Persons Covered

Effective Date

Policy Number

6. Is anyone listed on this application offered health coverage from a job? Check yes even if the coverage is from someone else's job, such as a parent or spouse. Yes If yes, you'll need to complete Attachment A. Is this a state employee benefit plan? Yes No

7. Have you or anyone listed on this application lost any health coverage in the last 2 months? Yes If yes, why was it lost? __________________ No

8. Was anyone in your household in Foster Care at age 18? Yes No

9. Does anyone in the household have any unpaid medical bills from the last 3 months? Yes No

10. Is anyone in your household American or Alaska Native? Yes No If Yes, complete Attachment B.

.

If you are applying for Aged, Blind or Disabled Medicaid please answer questions 11-16 and complete the Resources section. Otherwise, skip to the tax filer questions on page 3.

11. Are you or your spouse currently covered by Medicare?

Yes

No If Yes please list, ___________________________

12. Are you applying for Medicaid to cover unpaid medical bills from the three months prior to a

Supplemental Security Income (SSI) application?

Yes

No If yes, date of SSI application: _______________

13. Are you applying for someone who is now deceased and has unpaid medical bills within the last three

(3) months?

Yes

No

14. Are you applying for Medicaid to help pay for the care of a person who is in a nursing home?

Yes

No

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15. Are you applying for Medicaid for a person over the age of 18 whose SSI check has stopped?

Yes

No

16. Are you applying for Medicaid to help pay for community based waiver services such as Community

Care Services, NOW/COMP, Hospice Care, Independent Care Waiver or the Deeming Waiver (Katie

Beckett)?

Yes

No

Resources: Check all resources (assets) owned by you, your spouse, your dependents or jointly owned with someone else. Attach additional pages if necessary.

Checking Accounts Yes No

Funeral Plans/Prepaid Burial Item Yes No

Savings Accounts Yes No

Burial Plots or Contracts

Yes No

Government Bonds Yes No

Stocks and Bonds

Yes No

Trust Funds

Yes No

Other (IRA, CD, etc.)

Yes No

Real Property/Homeplace Property

Yes No

Have you or your spouse given away any assets for less than its value?

Yes No

If you answered yes to any of these questions, please describe below. Type of Resource Account/Policy Number Value Name of Bank, Insurance Company, etc.

Does anyone in the household own a vehicle? If so, please describe below.

Yes No

Vehicle Make

Model

Year

Amount Owed

Do you or your spouse have a life insurance policy?

If yes, please complete the following information.

Policy Owner

Insurance Company Policy Number

Face Value

Yes No Cash Value

Tax Filer Information

1. Does anyone in the household plan to file a federal income tax return NEXT YEAR? Yes No If yes, who? (list each person who plans to file)________________________________________________

2. Will any of the tax filers listed file jointly with a spouse? Yes No If yes, please list spouse's name:______________________

3. Will any of the tax filers claim any dependents on their tax return? Yes No If yes, please list name(s) of dependents:______________________________________________________________

4. Will anyone be claimed as a dependent on someone else's tax return? Yes No If yes, please list the name of the tax filer and the dependent:_(Filer)____________________________________ (Dependent)______________________________________________________ How is the tax dependent related to the tax filer? _____________________________

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Income and Earnings: List all types of earnings and income that your household receives. List the income amount before deductions such as taxes, insurance or Medicare premiums , health insurance, dental, and vision premiums or Spending accounts are taken out.

Income Type

Gross amount

Wages/Salary Current Employer: Wages/Salary Current Employer: Self Employment Unemployment Benefits Social Security Income SSI Worker's Compensation Pension/Retirement Benefits Veterans Benefits Child Support Alimony Contributions Other Income (please specify)

How often? (weekly, every 2

weeks, monthly, etc.)

Name of Person Receiving

Does anyone expect any change in monthly income? Yes

No

If yes, please list who expects the change, the type of income that is changing, and the date it is expected

to change below.

__________________________________________________________________________________

Deductions: Check all that apply, and give the amount and how often you pay it.

Alimony $________ How often? ________ Other Deductions $__________ How often?______

Student loan interest $_________ How often?__________

Assignment of Rights of Payment for Medical Support and Other Medical Care:

(If you are applying on behalf of another individual and do not have the power to execute an assignment for that individual, the individual will need to execute an assignment of the rights described below, as a condition of his/her eligibility for Medicaid.) As a condition of my eligibility, I agree to assign to the State all rights to medical support and to payment for medical care from any third party (hospital and medical benefits). I agree to cooperate with the state in identifying and providing information to assist the state in pursuing any third party who may be liable to pay for care and services. I understand that I must report any payments received for medical care within ten days. I agree to give the State the right to require an absent parent to provide medical insurance, if available. I understand I must get medical support from the absent parent if it is available and must cooperate with the Division of Child Support Services in obtaining this support. If I do not cooperate, I understand I may lose my Medicaid benefits, and only my child(ren) will receive benefits unless good cause is established.

I certify, under penalty of perjury, that all the information listed is truthful to the best of my knowledge.

____________________________________________________

Signature

____________________________

Date

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DECLARATION OF CITIZENSHIP/IMMIGRATION STATUS

Georgia Department of Human Services Division of Family and Children Services

I understand that the Georgia Division of Family and Children Services (DFCS) may require verification from the United States Department of Homeland Security (DHS) of my and/or my child(ren)'s citizenship or immigration status when seeking benefits. Information received from DHS may affect my or my child(ren)'s eligibility.

Please fill out and sign ONE or BOTH of the following statements as it pertains to the status of each person seeking benefits.

CHILDREN SEEKING BENEFITS

Name

Place of Birth ( City, State, Country)

(Check applicable)

Lawfully

U.S.

Admitted

Citizen Immigrant

Date Naturalized or Admitted into U.S.

Immigration Document ID #

(If applicable)

(If applicable)

AAAAA-

I, ________________________, declare the child/children is/are a U.S. Citizens or a Qualified Immigrant.

(PRINT NAME)

I attest to the identity of the child/children listed above, and certify under penalty of perjury, that the information written and checked above is true.

______________________________________________ ________________________

SIGNATURE (PARENT/GUARDIAN)

(DATE)

ADULT(S) SEEKING BENEFITS

Name

Place of Birth ( City, State, Country)

(Check applicable)

Lawfully

U.S.

Admitted

Citizen Immigrant

Date Naturalized or Admitted into U.S.

Immigration Document ID #

(If applicable)

(If applicable)

AA-

I, _______________________ , declare I am a U.S. Citizen or a Qualified Immigrant. I certify under

(PRINT NAME)

penalty of perjury, that the information written and checked above is true.

_____________________________________________ ________________________

SIGNATURE

(DATE)

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