Apply For Peachcare Form PDF Details

Securing affordable healthcare for children is a crucial step towards ensuring their well-being and healthy development. The Apply For PeachCare form is an essential document for parents and guardians in the state of Georgia who are seeking to enroll their kids in PeachCare for KidsTM, a comprehensive health care program designed to provide medical coverage for children under 19 at a low cost. Instructing applicants to use blue or black ink, the form is available for both online and paper submissions, highlighting its accessibility. It encompasses various sections that collect detailed information, starting with parent/guardian identification, which ensures that communication is directed towards the right person. It also seeks information about each child applying for the program, including their citizenship status, race, and existing health insurance coverage, emphasizing the program's inclusive and detailed approach to applicant evaluation. Insurance and employment details of the parent or guardian, coupled with income and daycare expenses, form a basis for assessing the financial eligibility and needs of the applying family. Additionally, a segment dedicated to documenting proof of income and citizenship underlines the program's commitment to thorough verification processes. Moreover, considerations such as current pregnancy within the household and the certification, understanding, and authorization section, highlight PeachCare's holistic approach to applicant assessment. Also noted is the potential for Medicaid eligibility, showcasing the program's dedication to ensuring children receive necessary medical coverage, even if they do not qualify for PeachCare directly. This form serves as a gateway for many families to affordable peace of mind regarding their children's health care coverage.

QuestionAnswer
Form NameApply For Peachcare Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namespeach care for kids application, georgia peachcare application, peachcare renewal, peachcare for kids application form

Form Preview Example

Sample - Use Blue or Black Ink

Yes

T E S T B O X

No

 

You can also apply online by visiting www.peachcare.org

NOW YOU CAN AFFORD PEACE OF MIND.

Correspondencia en Español

(Check this option if you would like to receive Correspondence in Spanish)

PeachCare Application

If you have ever applied for PeachCare for KidsTM - or - have ever been on PeachCare for KidsTM please call 877-GA PEACH

 

(427-3224). Filling out a new application will delay your processing.

Section 1. Parent/Guardian Information (Person to whom correspondence should be directed.) List only people currently living in the household.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

M

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PARENT ONE: Name

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

F

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First

 

 

 

 

 

M.I.

 

 

 

 

 

 

 

 

 

 

 

Last

 

 

 

 

 

 

 

 

 

 

 

Suffix

 

Sex

 

Date of Birth MM/DD/YY

 

Street Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Number and street, including apartment number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State

 

 

 

 

 

 

 

 

 

 

Zip Code

 

 

 

 

 

 

 

County

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(If different from street address)

 

 

 

 

 

 

 

 

 

 

Number and street, including apartment number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

 

 

 

 

 

 

 

 

 

 

 

 

State

 

 

 

 

 

 

 

 

 

 

Zip Code

 

 

 

 

 

 

 

County

 

Social Security Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home Telephone:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Business Telephone: (

 

 

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Emergency Telephone:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

E-Mail Address: ______________________________________

 

(

(

)

)

PARENT TWO:

Does parent two live in household?

Yes

No

(List parent two only if he/she lives in household.)

 

 

Name

 

 

 

 

M

 

 

 

 

 

 

 

F

 

 

 

First

M.I.

 

Last

Suffix

Sex

Date of Birth

MM/DD/YY

 

Social Security Number:

 

 

 

Business Telephone: (

 

)

 

Section 2. Child Information. List all children under 19 years old in your home. (If there are more than 3 children in household for whom you wish to

 

apply, please attach a separate sheet.) The name of the child(ren) should be the same as it appears on the child(ren)’s birth certificate.

 

 

 

 

 

 

 

M

 

 

 

 

CHILD ONE:

Name

 

 

 

 

 

F

 

 

 

 

 

 

First

 

M.I.

Last

Sex

Date of Birth

MM/DD/YY

 

U.S. Citizen?

Yes

No

 

Race

American Indian or Alaska Native

Asian

 

 

 

 

 

 

 

 

 

Black or African American

Hispanic or Latino

 

 

 

Social Security Number

 

 

 

Native Hawaiian or Other Pacific Islander

White

Other

 

What state was the child born in?

What county was the child born in?

 

 

 

 

 

 

Has Health Insurance?

Yes

No

Name of Insurance Company

 

 

 

 

 

 

Policy #

 

 

 

 

Medicaid #

 

 

 

 

 

 

Relationship to Parent #1:

Child

Stepchild

Grandchild/relative

Other

 

 

 

 

 

Relationship to Parent #2:

Child

Stepchild

Grandchild/relative

Other

 

 

 

 

CHILD TWO:

Name

 

 

 

 

 

M

 

 

 

 

 

 

 

 

 

F

 

 

 

 

 

 

First

 

M.I.

Last

Sex

Date of Birth

MM/DD/YY

 

U.S. Citizen?

Yes

No

 

Race

American Indian or Alaska Native

Asian

 

 

 

 

Social Security Number

 

 

 

Black or African American

Hispanic or Latino

 

 

 

 

 

 

Native Hawaiian or Other Pacific Islander

White

Other

 

 

 

 

 

 

 

What state was the child born in?

What county was the child born in?

 

 

 

 

 

 

Has Health Insurance?

Yes

No

Name of Insurance Company

 

 

 

 

 

 

Policy #

 

 

 

 

Medicaid #

 

 

 

 

 

 

Relationship to Parent #1:

Child

Stepchild

Grandchild/relative

Other

 

 

 

 

 

Relationship to Parent #2:

Child

Stepchild

Grandchild/relative

Other

 

 

 

 

CHILD THREE:

Name

 

 

 

 

 

M

 

 

 

 

 

 

 

 

 

F

 

 

 

 

 

 

First

 

M.I.

Last

Sex

Date of Birth

MM/DD/YY

 

U.S. Citizen?

Yes

No

 

Race

American Indian or Alaska Native

Asian

 

 

 

 

 

 

 

 

 

Black or African American

Hispanic or Latino

 

 

 

Social Security Number

 

 

 

Native Hawaiian or Other Pacific Islander

White

Other

 

 

 

 

 

 

 

What state was the child born in?

What county was the child born in?

 

 

 

 

 

 

Has Health Insurance?

Yes

No

Name of Insurance Company

 

 

 

 

 

 

Policy #

 

 

 

 

Medicaid #

 

 

 

 

 

 

Relationship to Parent #1:

Child

Stepchild

Grandchild/relative

Other

 

 

 

 

 

Relationship to Parent #2:

Child

Stepchild

Grandchild/relative

Other

 

 

 

 

 

 

 

Section 3. Insurance Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is either parent employed by the State of Georgia, a public school system or the Board of Regents? Yes

 

No

 

 

 

 

 

 

 

If yes, please specify ________________________________________________________________ Is this employment: Full Time

 

Part Time

 

Have any children you are applying for lost health insurance coverage (not Medicaid) in the past six months?

Yes

No

 

 

 

 

 

 

 

If yes, explain: _______________________________________________________________________ Last date of coverage:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MM/DD/YY

You may name your current doctor if he/she participates in Georgia Better Health Care. If you don’t make a choice, you will be assigned to a doctor convenient to where you live. You may change your selection later by calling 770-570-3373 (metro Atlanta) or 1-866-211-0950 (Toll-Free).

Section 4. Income and Daycare*

List ALL income received BY parents and children listed on your application. Do not list income for parent who DOES NOT live at this address. Do not list income of a legal guardian or other non-parent. Be sure to show the amount of income BEFORE TAXES and other deductions. Attach an extra sheet if needed.

INCOME:

AMOUNT

HOW OFTEN?

NAME OF PERSON RECEIVING

DID YOU INCLUDE

(Include only income of the children/parents at the address

 

BEFORE Taxes and Other Deductions (Weekly, Monthly, Every 2 weeks, Etc.)

PROOF OF INCOME?

 

listed on the application)

 

 

 

 

 

Current employer’s name:

 

 

 

 

 

__________________________

 

 

 

Yes

No

 

 

 

 

 

Current employer’s name:

 

 

 

 

 

__________________________

 

 

 

Yes

No

 

 

 

 

 

Social Security (RSDI)

 

 

 

Yes

No

Supplemental Security Income

 

 

 

Yes

No

Workers’ Compensation

 

 

 

Yes

No

Pensions or Retirement Benefits

 

 

 

Yes

No

Child Support

 

 

 

Yes

No

(List amount each child receives.)

 

 

 

 

 

Contributions

Yes

No

Unemployment Benefits

Yes

No

Other Income, please specify:

Yes

No

__________________________

 

 

* Do you pay for childcare (or care for an adult who cannot care for himself/herself) so that someone in your household can work?

NAME OF PARENT

NAME OF CHILD OR

UNDER THE AGE OF 2?

NAME OF DAY CARE

AMOUNT

HOW OFTEN?

WHO WORKS

ADULT CARED FOR

 

 

OR CAREGIVER

PAID

(Weekly, Monthly, Etc.)

 

 

Yes

No

 

 

 

 

 

Yes

No

 

 

 

 

 

Yes

No

 

 

 

Section 5. Proof of Income and Citizenship

You must include the most recent copies of proof of all your income. These are the types of information you need to send with your application: For money you earn by doing a job or service, you must send:

Weekly pay - (4) weeks of pay stubs (one week after the other)—ORBi-Weekly pay - (2) pay stubs received every other week (one after another)— OR—Semi-Monthly - (2) pay stubs received two times a month (one after the other)—ORMonthly - (2) pay stubs received one time a month (one month after another)—ORPaid Cash - Letter from Employer signed by an Officer of the Company on Company letterhead—ORYearly - Tax Forms filed—ORSelf Employment Documents - such as business ledger receipts—OR—Bank Deposits.

Please show proof of money anyone in the household receives from any agencies, parents or relatives, or any other sources. This might include:

SSI or SSA - Current year award letter • Unemployment check - (4) weeks of pay stubs (one week after the other) • Workers’ Compensation -

letter from insurance company stating amount received and how often received, provide contact name and number. • Contributions - letter from person who gives you money, provide name, address and contact number. Provide amount received and how often received. • Child Support (paid directly to you) - written statement from the parent who gives you money, provide the name, address and contact number. Provide amount received and how often received. • Child Support (paid through court) - court papers or letter stating the amount of income received and how often it is received. • Other Unearned Income - provide letter stating amount received and how often received. Provide name, address and contact number or (4) weeks of pay stubs (one week after the other). Citizenship or legal immigration status must be verified for eligibility in PeachCare or Medicaid. PeachCare MAY request proof of citizenship or legal immigration status. Failure to comply will result in a denial of your application. Social Security Numbers are used to do computer matches with other agencies in order to assist in verifying eligibility for PeachCare and/or Medicaid benefits. You only need to tell us the Social Security Number for the people for whom you are applying.

Section 6. Pregnancy

Is anyone in the household pregnant?

Yes

No

If yes, who? _____________________________________________________

Section 7. Certification, Understanding, and Authorization

I understand that this information will be verified to determine eligibility. I understand that information supplied by the Georgia Department of Labor, Georgia Department of Revenue, the Social Security Administration or other agencies may be disclosed to a third party administrator to verify and determine eligibility for PeachCare. I agree to cooperate with PeachCare for KidsTM , the Georgia Department of Community Health, and the Georgia Division of Family and Children Services to verify income, resources, citizenship and identification. I agree to assign to the state all rights to medical support and third party support payment (hospital and medical benefits).

I understand that I must report changes in my address, income, resources, and circumstances within ten (10) days of becoming aware of the change. I attest to the identity/citizenship/legal residency status of the children listed and I certify under penalty of perjury that all of the information provided on this application is true and correct to the best of my knowledge.

PLEASE NOTE: If your child is not eligible for PeachCare, he/she might qualify for Medicaid. Your application will be referred to Medicaid for review. Medicaid offers the same benefits as PeachCare and does not require a premium. Medicaid may be able to assist with unpaid medical bills from the past three months. If your child(ren) is eligible for Medicaid, you must agree to apply for a Social Security Number for your child(ren).

Do you have any unpaid medical bills from the past three months? Yes

No

If yes, what month(s)_________________________

I authorize release of personal and financial information to PeachCare for KidsTM, the Georgia Department of Community Health and the Division of Family and Children Services. I understand that my case may be subject to a quality control review and I agree to cooperate in the review process.

SIGNATURE OF PARENT OR GUARDIAN: (REQUIRED) _____________________________________________________ Date ______________

Where did you get this application? Dr.’s Office/Hospital 1-877-GA-PEACH

Once your application has been approved, you will receive a letter letting you know the amount of your monthly premium.

Georgia Department of Community Health

Rev 11/04/10

School/Daycare

Health Dept.

 

Caseworker

Other

 

 

 

 

Check/Money Order attached? Yes

No

Amount ____________________

Please mail application and income documents to:

 

Eligibility will not be affected by

 

 

 

 

PeachCare for KidsTM

 

 

 

race, color, national origin, age,

P.O. Box 2583

 

 

 

disability, or sex except where

 

 

 

it is required by law.

Atlanta, GA 30301-2583

 

 

 

 

 

 

 

 

 

 

 

Faxed applications are not accepted.

Si desea una aplicación en español, por favor llame gratis al 1-877-427-3224.

How to Edit Apply For Peachcare Form Online for Free

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Completing this document demands thoroughness. Make sure every blank field is filled out accurately.

1. Complete your peachcare renewal with a group of major blank fields. Note all the information you need and ensure there is nothing forgotten!

Stage number 1 of filling out peachcare for kids application

2. Once the previous array of fields is done, you need to insert the essential specifics in Social Security Number, Business Telephone, Suffix , Section Child Information List, apply please attach a separate, CHILD ONE, Name, First, Last, M F Sex, Date of Birth MMDDYY, US Citizen Yes, Race, Social Security Number, and American Indian or Alaska Native in order to go to the third step.

Completing section 2 of peachcare for kids application

3. This subsequent part is typically rather simple, Has Health Insurance Yes, Name of Insurance Company, Policy , Medicaid , Relationship to Parent Child, Relationship to Parent Child, Stepchild, Stepchild, Grandchildrelative, Grandchildrelative, CHILD THREE Name, First, Last, Other, and Other - every one of these empty fields will have to be completed here.

Completing part 3 in peachcare for kids application

4. This particular part arrives with all of the following blanks to complete: Is either parent employed by the, If yes please specify Is this, Part Time, Have any children you are applying, Yes, If yes explain Last date of, and MMDDYY.

Step # 4 of completing peachcare for kids application

As to Have any children you are applying and Yes, be certain you do everything correctly in this section. Both of these are certainly the most significant fields in the file.

5. To finish your document, the final part has a couple of additional fields. Typing in Current employers name, Current employers name, Social Security RSDI, Supplemental Security Income, Workers Compensation, Pensions or Retirement Benefits, Child Support List amount each, Contributions, Unemployment Benefits, Other Income please specify , BEFORE Taxes and Other Deductions, Weekly Monthly Every weeks Etc, NAME OF PERSON RECEIVING Include, listed on the application, and DID YOU INCLUDE PROOF OF INCOME will certainly finalize everything and you're going to be done in no time at all!

Part number 5 for filling out peachcare for kids application

Step 3: Immediately after proofreading your fields, click "Done" and you're good to go! Try a free trial subscription with us and gain direct access to peachcare renewal - with all transformations kept and available inside your personal account page. FormsPal is invested in the personal privacy of our users; we make certain that all personal information entered into our system remains confidential.