Apply For Peachcare Form – Fill Out and Use This PDF

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

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)—OR—Bi-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)—OR—Monthly - (2) pay stubs received one time a month (one month after another)—OR—Paid Cash - Letter from Employer signed by an Officer of the Company on Company letterhead—OR—Yearly - Tax Forms filed—OR—Self 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 ______________