Alabama Form 211 PDF 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.

Form NameAlabama Form 211
Form Length8 pages
Fillable fields0
Avg. time to fill out2 min
Other namesform 211 medicare, alabama form 211, alabama form 211 address, alabama medicaid application print out

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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

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


Please print clearly using dark ink.












































Mailing Address __________________________________________________________________________








Street or 911 Address


















Zip Code




Phone # (_______)_________________

Other Phone (_______)_________________ Whose? _________________________


email ___________________________________________

Fax ________________________________


Current Resident Address __________________________________________________________________









(If different from Mailing Address)



















Zip Code



County of Residence ______________________________ Date of Birth ____________________________


Social Security # _______________________________

Medicaid # ______________________________















Marriage Information










I am Married _________________ (Date Married)
















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








I am Single (Never Married)


I am Divorced ________________ (Date Divorced)




I am Widowed _______ (Date Widowed)

I am Separated _______________ (Date Separated)
























Do you have Medicare Part A (Hospital) Coverage?

Yes No







Name on Medicare card _______________________________________________________________


Medicare # ________________________________________________________


















American Indian

Hispanic Asian



















































District Offi ce Use Only







Date Received ____________

Date Accepted ____________





Medicare Card Received Yes No

Income Verification Received































Form 211 (Revised 5/2014)

Alabama Medicaid Agency

Applicant’s Name __________________________________________ SS # ________________________________



List names of anyone living in your home














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 _________________________













email ______________________________________________

FAX ____________________________










(Complete even if divorced, separated or widowed.)




Name ______________________________________________

Phone # (_______)___________________




(First, Middle, Last)








Address ____________________________________________

Date of Birth _______________________




(Street or Box Number)








SS # ______________________________













email _________________________________________ Spouse’s Medicaid # _______________________












(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












2. Former Spouse’s Name _______________________________________

SS # ______________________




Marriage Began _________________ Ended ______________

Reason Death Divorce Other










Page 2

Applicant’s Name ___________________________________________ SS # ________________________________















Are you a Veteran? Yes No












Are you a dependent of a Veteran? Yes









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





Veteran Name ____________________________________________________________________________














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.




































Are you a United States Citizen? Yes No


Are you a lawfully admitted alien?  Yes No






Where were you born?______________________________________________________________________













Do you live in Alabama and plan to stay?










What language do you usually speak?


English Spanish Other___________________



Do you or a family member speak English?









Have you ever applied for or received SSI?





 No





If yes, were you terminated from SSI?

When? _____________________________






























































Do you have medical insurance other than Medicare?




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 # ________________________________











(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











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



















How Often







Minor Child




Type of Income











Claim Number





Annually, etc.)











Social Security









(include Medicare Premiums)









SSI (Gold Check)


















Public Assistance (Welfare)


















Railroad Retirement


















Veterans Benefits, Pensions,









Compensation or Insurance


















Federal Civil Service Annuity


















State Retirement/Pension


















Private Pension


















Miner’s Benefits


















Black Lung Benefits


















Cash Contributions (from









relatives, friends, others)









Rental (land, buildings, or









from roomer)


















Personal loans (relatives,









friends, others)















14. Unemployment Compensation
















Insurance Annuity or Proceeds
















Government Payments on land








Coal, Oil, Gravel Rights and









Timber Leases




































Court Ordered Support



































Other: Specify ____________
















Other: Specify ____________

















Legal Settlements


















Sheltered Workshop Earnings
















25. Wages/Salary


















Self Employment

























Page 4










Applicant’s Name ___________________________________________ SS #________________________________


*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.


*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.


*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.


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# ________________________________


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 __________.


__________________________________________________ _____________________________________________

(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).


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 __________.


__________________________________________________ _____________________________________________

(Signature of Sponsor/Representative)

__________________________________________________ _____________________________________________



(City, State, Zip)


(Telephone Number)

Page 6

How to Edit Alabama Form 211 Online for Free

We've used the endeavours of our best software engineers to make the PDF editor you intend to work with. The application will help you fill out the alabama form 211 address document easily and don’t waste time. All you have to do is stick to the next simple tips.

Step 1: On the following website page, press the orange "Get form now" button.

Step 2: The document editing page is right now available. You can include text or update present data.

Type in the information requested by the application to prepare the file.

form 211 alabama medicaid fields to fill in

Write down the necessary data in the segment I am Divorced Date Divorced I, I am Separated Date Separated, 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, Date Received Date Accepted, Medicare Card Received Yes No, and Income Verifi cation Received Yes.

Entering details in form 211 alabama medicaid step 2

Type in the obligatory data once you are on the Applicants Name SS FAMILY SIZE, List names of anyone living in, Name, Age, Relationship, SPONSOR, If the applicant is unable to, Relationship to Applicant, Name Home Phone, and Address Work Phone section.

form 211 alabama medicaid Applicants Name  SS    FAMILY SIZE, List names of anyone living in, Name, Age, Relationship, SPONSOR, If the applicant is unable to, Relationship to Applicant, Name  Home Phone, and Address  Work Phone blanks to fill out

Inside of paragraph Cell Phone City, Zip, State, email FAX, SPOUSE INFORMATION, Complete even if divorced, Name Phone, First Middle Last, Address Date of Birth Street or, City, State, Zip, County, email Spouses Medicaid, and FORMER SPOUSE INFORMATION, specify the rights and obligations.

Completing form 211 alabama medicaid step 4

End up by reading all these sections and filling them in correspondingly: Marriage Began Ended Reason, Date, Former Spouses Name SS, Marriage Began Ended Reason, Date, and Page.

stage 5 to completing form 211 alabama medicaid

Step 3: When you choose the Done button, your finalized document can be easily transferred to all of your devices or to electronic mail specified by you.

Step 4: Be sure to prevent possible difficulties by preparing around a pair of duplicates of the document.

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