Form 211 Alabama Medicaid Details

Alabama Form 211 is a tax form used to report and pay certain taxes. This form is used to report and pay the Alabama income tax, the Alabama estate tax, and the Alabama inheritance tax. This form must be filed by individuals or businesses that owe any of these taxes. The deadlines for filing this form vary depending on which tax is being paid, so be sure to check the instructions carefully. Penalties may apply for late or incorrect filings. For more information, contact the Alabama Department of Revenue.

This general guide will allow you to figure out just how long it will require you to complete alabama form 211, the number of pages it has, and some additional specific details about the file.

QuestionAnswer
Form NameAlabama Form 211
Form Length8 pages
Fillable?Yes
Fillable fields292
Avg. time to fill out30 min 14 sec
Other namesmedicaid form 211, medicare 211 form, alabama medicaid form 211, alabama medicare saving program form 211

Form Preview Example

Alabama Medicaid Agency

Application for Medicare Savings Programs

This is NOT an application for full Medicaid.

These programs cover Medicare premiums and deductibles. Medicaid’s drug coverage is limited to the drugs covered under Medicare Part D only. Medicaid will not pay for any excluded drugs under Medicare Part D.

Instructions: Read this application carefully and follow all instructions given throughout the form. Answer each question completely and accurately.

1.Send a copy of your Medicare card to verify your Part A coverage.

2.Send a copy of your Social Security card.

3.Send verifi cation of the gross (before taxes) amount of your monthly income.

4.Sign the application.

5.Mail the application to the District Offi ce serving your county.

(See attachment for the address of the District Offices.)

Form 211 (Revised 5/2014)

Alabama Medicaid Agency

 

www.medicaid.alabama.gov

Notice to Applicants and Sponsors

Federal and state laws provide both criminal and civil penalties for false statements or material omissions in an application for Medicaid benefi ts or payments. Also, any application found to contain material misstatements or omissions will be denied.

The following statutes are excerpts from the Code of Alabama pertaining to the Medicaid program:

S22-1-11. Making false statement or representation of material fact in claim or application for payments on medical benefi ts from Medicaid agency generally; kickbacks, bribes, etc.; exceptions; multiple offenses.

(a)Any person who, with intent to defraud or deceive, makes, or causes to be made or assists in the preparation of any false statement representation or omission of a material fact in any claim or application for any payment, regardless of amount, from the Medicaid agency, knowing the same to be false; or with intent to defraud or deceive, makes, or causes to be made, or assists in the preparation of any false statement, representation or omission of a material fact in any claim or application for medical benefits from the Medicaid agency, knowing the same to be false; shall be guilty of a felony and upon conviction there of shall be fi ned not more than $10,000.00 or imprisoned for not less than one nor more than five years, or both.

* * *

(e)Any two or more offenses in violation of this section may be charged in the same indictment in separate counts for each offense and such offense shall be tried together, with separate sentences being imposed for each offense of which defendant is found guilty. (Acts 1980, No. 80-539, p. 837, Sections 1-5.)

S22-6-8, Revocation of eligibility of recipient upon determination of abuse, fraud, or misuse of benefits; when eligibility may be restored.

(a)Upon determination by a utilization review committee of the designated state Medicaid agency that a Medicaid recipient has abused, defrauded, or misused the benefi ts of the program said recipient shall immediately become ineligible for Medicaid benefits.

(b)Medicaid recipients whose eligibility has been revoked due to abuse, fraud or other deliberate misuse of the program shall not be deemed eligible for future Medicaid services for a period of not less than one year and until full restitution has been made to the designated state Medicaid agency.

(c)The provisions of this section shall not be effective if they are found by a court of competent jurisdiction to contravene federal laws or federal regulations applicable to the Medicaid program.

(Acts 1980, No. 80-127, p.190.)

Medicaid Eligibility Policies and Procedures are in compliance with Civil Rights Act of 1964,

Section 504 of the Rehabilitation Act of 1973, Federal Age Discrimination Act of 1975

and the Americans with Disabilities Act of 1990.

Form 211

 

Application for Medicare Savings Programs

5-2014

Please print clearly using dark ink.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1

APPLICANT

 

 

 

 

 

 

 

Name___________________________________________________________________________________

 

 

 

 

 

 

 

 

First

Middle/Maiden

 

Last

Suffix

 

 

Mailing Address __________________________________________________________________________

 

 

 

 

 

 

 

Street or 911 Address

 

 

 

 

 

 

________________________________________________________________________________________

 

 

 

 

 

 

City

 

State

 

Zip Code

 

 

 

Phone # (_______)_________________

Other Phone (_______)_________________ Whose? _________________________

 

email ___________________________________________

Fax ________________________________

 

Current Resident Address __________________________________________________________________

 

 

 

 

 

 

 

 

(If different from Mailing Address)

 

 

 

 

 

________________________________________________________________________________________

 

 

 

 

 

 

 

City

 

State

 

 

Zip Code

 

 

County of Residence ______________________________ Date of Birth ____________________________

 

Social Security # _______________________________

Medicaid # ______________________________

 

 

 

 

 

 

 

 

 

 

 

 

2

MARITAL STATUS

Marriage Information

 

 

 

 

 

 

 

 

 

I am Married _________________ (Date Married)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If married, does your spouse have Medicare?  Yes

No

 

 

 

 

 

 

I am Single (Never Married)

 

I am Divorced ________________ (Date Divorced)

 

 

 

I am Widowed _______ (Date Widowed)

I am Separated _______________ (Date Separated)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3

MEDICARE

 

 

 

 

 

 

 

Do you have Medicare Part A (Hospital) Coverage?

Yes No

 

 

 

 

 

 

Name on Medicare card _______________________________________________________________

 

Medicare # ________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

4

RACE

White

Black

American Indian

Hispanic Asian

Other_________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5

SEX

Female

Male

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

District Offi ce Use Only

 

 

 

 

 

 

Date Received ____________

Date Accepted ____________

 

 

 

 

Medicare Card Received Yes No

Income Verification Received

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Form 211 (Revised 5/2014)

Alabama Medicaid Agency

Applicant’s Name __________________________________________ SS # ________________________________

6

FAMILY SIZE

List names of anyone living in your home

Name

Age

Relationship

_______________________________________________

_______

________________________________________________

_______________________________________________

_______

________________________________________________

_______________________________________________

_______

________________________________________________

7

SPONSOR (If the applicant is unable to complete the application or provide additional information, the Medicaid sponsor should be the person most familiar with the fi nancial situation of the applicant.) Please complete the Appointment of Representative form on Page 6 of this application.

 

 

 

Relationship to Applicant ______________________________

 

 

 

 

 

Name ______________________________________________

Home Phone ________________________

 

 

 

Address ____________________________________________

Work Phone ________________________

 

 

___________________________________________________

 

 

 

 

___________________________________________________

Cell Phone _________________________

 

 

 

City

State

 

Zip

 

 

 

 

 

email ______________________________________________

FAX ____________________________

 

 

 

 

 

 

8

 

SPOUSE INFORMATION

(Complete even if divorced, separated or widowed.)

 

 

 

Name ______________________________________________

Phone # (_______)___________________

 

 

 

(First, Middle, Last)

 

 

 

 

 

 

 

Address ____________________________________________

Date of Birth _______________________

 

 

 

(Street or Box Number)

 

 

 

 

 

 

__________________________________________________

SS # ______________________________

 

 

 

City

State

Zip

County

 

 

 

 

 

email _________________________________________ Spouse’s Medicaid # _______________________

 

 

 

 

 

 

 

9

 

FORMER SPOUSE INFORMATION

 

(Must be completed if you are widowed or divorced.)

 

 

 

(For all previous marriages, list most recent first.)

 

 

 

 

 

1. Former Spouse’s Name ________________________________________

SS # _____________________

 

 

 

Marriage Began _________________ Ended ______________

Reason Death Divorce Other

 

 

 

 

Date

 

Date

 

 

 

 

2. Former Spouse’s Name _______________________________________

SS # ______________________

 

 

 

Marriage Began _________________ Ended ______________

Reason Death Divorce Other

 

 

 

 

Date

 

Date

 

 

Page 2

Applicant’s Name ___________________________________________ SS # ________________________________

 

10

VETERAN’S STATUS

 

 

 

 

 

 

 

 

 

 

 

Are you a Veteran? Yes No

 

 

 

 

 

 

 

 

 

 

 

Are you a dependent of a Veteran? Yes

No

 

 

 

 

 

 

 

If yes to either of the questions above, complete the following:

 

 

 

 

Veteran Name ____________________________________________________________________________

 

 

First

 

 

Middle

 

 

 

Last

 

 

 

Veteran Claim Number __________________________ Relationship to Veteran _______________________

 

 

Have you applied for Veteran’s benefi ts under the new Veterans & Survivor’s Improvement Act? Yes No

 

 

If no, you must apply and send verification.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11

RESIDENCY INFORMATION

 

 

 

 

 

 

 

 

 

 

 

Are you a United States Citizen? Yes No

 

Are you a lawfully admitted alien? Yes No

 

 

 

 

 

Where were you born?______________________________________________________________________

 

 

City

 

County

 

 

 

State

Country

 

 

Do you live in Alabama and plan to stay?

 

Yes

 

 

No

 

 

 

 

What language do you usually speak?

 

English Spanish Other___________________

 

 

Do you or a family member speak English?

Yes

 

 

No

 

 

 

 

Have you ever applied for or received SSI?

 

Yes

 

 

 No

 

 

 

 

If yes, were you terminated from SSI?

When? _____________________________

 

 

 

 

 

 

 

 

Month/Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12

OTHER INSURANCE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you have medical insurance other than Medicare?

 

Yes

 

If yes, provide information below:

 

 

1. Name/Address of Health Insurance Company

 

 

 

2. Name/Address of Health Insurance Company

 

 

____________________________________________

 

_________________________________________

 

 

____________________________________________

 

_________________________________________

 

 

____________________________________________

 

_________________________________________

 

 

Policy # ________________________________

 

 

 

 

Policy # ________________________________

 

 

Group # ________________________________

 

 

 

 

Group # ________________________________

 

 

3. Name/Address of Health Insurance Company

 

 

 

4. Name/Address of Health Insurance Company

 

 

____________________________________________

 

_________________________________________

 

 

____________________________________________

 

_________________________________________

 

 

____________________________________________

 

_________________________________________

 

 

Policy # ________________________________

 

 

 

 

Policy # ________________________________

 

 

Group # ________________________________

 

 

 

 

Group # ________________________________

(You may list other policies on a separate sheet(s) and attach to this application, if needed.)

Page 3

Applicant’s Name _______________________________________

SS # ________________________________

 

 

 

 

 

 

 

 

13

GROSS INCOME:

(This means “money coming in” before anything is taken out). Answer the following.

 

Do you or your spouse have “money coming in” from any of the sources listed below?

Yes No

 

 

If yes, fi ll in the claim number and gross amount. (A copy of most recent check stub or other verifi cation must be

 

provided.)

 

 

 

 

 

 

 

 

NOTE: If you are applying on behalf of a married individual, the spouse must also answer these questions.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

How Often

 

 

 

 

Applicant

Spouse

Minor Child

 

Received?

 

Type of Income

 

 

Gross

Gross

Gross

 

(Quarterly,

 

 

 

Claim Number

Amount

Amount

Amount

 

Annually, etc.)

 

 

 

 

 

 

 

 

 

1.

Social Security

 

 

 

 

 

 

 

 

(include Medicare Premiums)

 

 

 

 

 

 

 

2.

SSI (Gold Check)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.

Public Assistance (Welfare)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

Railroad Retirement

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.

Veterans Benefits, Pensions,

 

 

 

 

 

 

 

 

Compensation or Insurance

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6.

Federal Civil Service Annuity

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7.

State Retirement/Pension

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8.

Private Pension

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

9.

Miner’s Benefits

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10.

Black Lung Benefits

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

11.

Cash Contributions (from

 

 

 

 

 

 

 

 

relatives, friends, others)

 

 

 

 

 

 

 

12.

Rental (land, buildings, or

 

 

 

 

 

 

 

 

from roomer)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

13.

Personal loans (relatives,

 

 

 

 

 

 

 

 

friends, others)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

14. Unemployment Compensation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

15.

Insurance Annuity or Proceeds

 

 

 

 

 

 

 

 

 

 

 

 

 

 

16.

Government Payments on land

 

 

 

 

 

 

17.

Coal, Oil, Gravel Rights and

 

 

 

 

 

 

 

 

Timber Leases

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

18.

Royalties

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

19.

Court Ordered Support

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

20.

N/A

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

21.

Other: Specify ____________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

22.

Other: Specify ____________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

23.

Legal Settlements

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

24.

Sheltered Workshop Earnings

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

25. Wages/Salary

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

26.

Self Employment

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 4

 

 

 

 

 

 

 

 

 

Applicant’s Name ___________________________________________ SS #________________________________

RELEASE OF INFORMATION

*I hereby authorize and give my consent for the Alabama Medicaid Agency to obtain information from any source for the purpose of determining my eligibility for Medicaid benefi ts. I authorize this release form to be in effect for as long as I am on Medicaid regardless of the date that it is signed. I further authorize copies of this document to be used in place of the original. I give my consent for the release of information for those purposes directly related to the administration of the Medicaid program. These purposes include, but are not limited to, establishing eligibility for benefi ts, determination of the amount of medical assistance received, the provision of services, and investigation of program violations.

AFFIRMATION AND AGREEMENT

*I give permission to the Alabama Medicaid Agency to use my Social Security number to get information about my resources and income from banks, fi nancial institutions, employers, and other county, state and federal agencies, and/or to see if I qualify for assistance or to see if I have insurance.

*If I am approved for Medicaid, I assign all insurance and medical support benefi ts to Medicaid. If Medicaid pays my bills, then my insurance or other benefi ts (such as lawsuit settlements) must be used to pay Medicaid back. I agree to help and cooperate with Medicaid in identifying and collecting this money, or I may lose my Medicaid benefi ts. I give permission for my insurance company, employer, and others to give needed information to Medicaid in order to administer the Medicaid program.

*I understand that if this application or other information shows that I may be eligible for payments or benefits from other sources, I am required to apply for them.

*I understand that my case is subject to review by State and Federal Quality Control and that I must cooperate in completing the application process or in any subsequent reviews of my eligibility, including reviews resulting from reported changes, recertifi cation, or as a part of a State or Federal Quality Control Review.

*I understand that resources that have been sold, transferred, disposed of, or given away within the past 60 months will not affect my application for Medicaid for the Medicare Savings Programs, but may affect eligibility for Medicaid in a medical institution.

RESPONSIBILITIES

*I agree to notify the Medicaid District Offi ce within ten (10) days, if there is a change in my address, living arrangements, family size, income or resources.

FALSE STATEMENTS

I know that anyone who makes or causes to be made a false statement, representation or omission of a material fact in an application or for use in determining eligibility for Medicaid commits a crime punishable under Federal or State law or both. I affi rm under penalty of perjury that all information I give in this document or in support of it is true.

___________________________________________________

Date _________________________

Signature of Applicant or Representative

 

___________________________________________________

Date _________________________

Signature of Applicant’s Spouse or Representative

 

___________________________________________________

Date _________________________

Witness’ Signature (If applicable)

 

Medicaid Eligibility Policies and Procedures are in compliance with the Civil Rights Act of 1964,Section 504 of the Rehabilitation Act of 1973, the Federal Age Discrimination Act of 1975 andthe Americans with Disabilities Act of 1990.

Page 5

Applicant’s Name _________________________________________ SS# ________________________________

APPOINTMENT OF REPRESENTATIVE

I hereby appoint ________________________________________________________________________ (Sponsor’s Name)

as my legal representative to act in my stead and on my behalf to apply, reapply and make claim for Medicaid benefits under Title XIX of the Social Security Act from the Alabama Medicaid Agency, hereby ratifying and confi rming the acts of my said representative on my behalf. This appointment authorizes my said representative to fully act in my stead in connection with all Medicaid matters involving me, including, but not limited to, making applications, reapplications and claims of all kinds, accepting and giving notice in connection with eligibility determinations and Fair Hearings, requesting information, and presenting and eliciting evidence. This appointment shall remain in full force and effect until I have notifi ed the Alabama Medicaid Agency in writing that this authority has been withdrawn.

Done this the ______________________ day of ________________________________________, 20 __________.

WITNESSES

__________________________________________________ _____________________________________________

(Signature of Medicaid Claimant)

__________________________________________________ _____________________________________________

(Social Security Number)

If claimant cannot sign his/her name but can make a mark; this is acceptable if witnessed by two adults.

The mark may be labeled. Example:

X (Her mark)

Jane Doe

.

If claimant cannot sign his/her name or make a mark and there is no one legally designated as guardian, conservator, etc., representative must answer the questions below.

What is your relationship to claimant? ________________________________________________________________

Why can’t claimant sign? __________________________________________________________________________

To what extent are you responsible for claimant? ________________________________________________________

If claimant has a legally appointed guardian, conservator or someone with durable power of attorney who will represent him/her for Medicaid purposes, claimant’s signature on this form is not required. Representative should sign the Representative portion of the form only and attach to this form a copy of evidence of legal authority to act on claimant’s behalf (Letter of Conservatorship/Guardianship or Durable Power of Attorney).

ACCEPTANCE OF APPOINTMENT

I hereby accept the foregoing appointment. I certify that I have not been suspended or prohibited from practice before the Alabama Medicaid Agency and am not otherwise disqualifi ed from acting as an appointed representative. I acknowledge that representations and applications made by me on behalf of the claimant are made under an affi rmation which subjects me to penalties for perjury and that false statements may subject me to penalties or fraud.

My relationship to the above is __________________________________________________ (Attorney, relative, etc.)

Done this the ______________________ day of ________________________________________, 20 __________.

WITNESSES

__________________________________________________ _____________________________________________

(Signature of Sponsor/Representative)

__________________________________________________ _____________________________________________

(Address)

__________________________________________________

(City, State, Zip)

__________________________________________________

(Telephone Number)

Page 6

How to Edit Alabama Form 211

The alabama medicaid application form 211 filling out course of action is very simple. Our PDF tool enables you to work with any PDF file.

Step 1: The first step will be to hit the orange "Get Form Now" button.

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alabama medicaid application print out blanks to consider

Please submit the   I am Married (Date Married), If married,   I am Divorced (Date Divorced),   I am Separated (Date, MEDICARE, Do you have Medicare Part A, Name on Medicare card , Medicare # , RACE,  White  Black  American Indian,  Other, SEX,  Female  Male, District Offi ce Use Only, and Date Received Date Accepted area with the demanded information.

alabama medicaid application print out   I am Married  (Date Married), If married,   I am Divorced  (Date Divorced),   I am Separated  (Date, MEDICARE, Do you have Medicare Part A, Name on Medicare card , Medicare # , RACE,  White  Black  American Indian,  Other, SEX,  Female  Male, District Offi ce Use Only, and Date Received  Date Accepted  blanks to complete

Note the essential data in Applicant’s Name SS # , List names of anyone living in, Age, Relationship, 6 FAMILY SIZE, Name, SPONSOR, (If the applicant is unable to, and Relationship to Applicant segment.

alabama medicaid application print out Applicant’s Name  SS # , List names of anyone living in, Age, Relationship, 6 FAMILY SIZE, Name, SPONSOR, (If the applicant is unable to, and Relationship to Applicant  blanks to insert

In the section Name Home Phone , Address Work Phone , Cell Phone City, Zip, State, email FAX , 8 SPOUSE INFORMATION, (Complete even if divorced, Name Phone # (), (First, Address Date of Birth (Street or, SS # , State, County, and City, place the rights and responsibilities of the sides.

alabama medicaid application print out Name  Home Phone , Address  Work Phone ,  Cell Phone  City, Zip, State, email  FAX , 8 SPOUSE INFORMATION, (Complete even if divorced, Name  Phone # (), (First, Address  Date of Birth  (Street or, SS # , State, County, and City fields to insert

Finalize by taking a look at the following areas and preparing them as required: (For all previous marriages, Marriage Began Ended Reason , Date, Date, Marriage Began Ended Reason , Date, Date, and Page 2.

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