Bhsf Form 1 Mpp – Fill Out and Use This PDF

Bhsf Form 1 Mpp is a two-year program offered by the University of Botswana.

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Bhsf Form 1 Mpp PDF Details

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Here are several details you might want to read before starting dealing with the bhsf form 1 mpp.

Question	Answer
Form Name	Bhsf Form 1 Mpp
Form Length	2 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	30 sec
Other names	medicaid application form louisiana, louisiana medicaid application printable, what does the louisiana medicaid renewal form look like for 2018, louisiana printable application for medicaid

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BHSF Form 1-MPP

Rev. 04/05

Prior Issue Obsolete

For Agency Use Only

Request date

(Application date)

Date mailed

Agency Rep

To protect your application date, we must receive this application by

(for agency use only)

What language do you speak best? English Spanish Vietnamese Other (specify) What language do you write best? English Spanish Vietnamese Other (specify)

If you do not speak English we can get interpreter services to help at no cost to you. If you need help to fill out this form, call your local Medicaid office or call us toll free at 1+888+544-7996. If you are deaf or have hearing problems, call the TTY line toll free at 1+800+220-5404.

This application is to get healthcare coverage for persons with disabilities who work and who are at

least age 16 but not yet age 65. If you want Medicaid for anyone else, check ( ) this . We will send you information about applying for other Medicaid coverage. Please fill out every item on this form. If an answer to a question is none or 0, write “none”. If you need more space for any item, use a separate sheet.

1.Tell us who YOU are, where YOU live, and where YOU get your mail:

Name

Parish

Home address

City

State

Zip code

Mailing address

City

State

Zip code

Home phone ( )

Daytime phone (

)

2.Tell us about yourself and your spouse. You do not have to give your spouse’s Social Security number if he or she is not applying. If given, the number will only be used to verify assets.

You do not have to give race information. If you choose to do so, use the following codes: 1=White; 2=Black; 3=American Indian/Alaskan; 4=Asian; 5=Hispanic/Latino; 6=Hawaiian/Pacific Islander; 7=Hispanic/Latino & Other; 8=Multi-Race, Not Hispanic; 9=Unknown

Name - first, middle initial, last	Social Security	Date of birth			Sex	Race	US citizen/	Louisiana	Relation to you
	number	Month	Day	Year	M/F		Legal alien	resident

Yes	No	Yes	No	self



Yes	No	Yes	No	spouse
				spouse

3.Tell us about EACH job or business that you have. Show the amount of total or gross income before any deductions, not your take-home pay. (Send copies of pay check stubs or other proof of your earnings for last month. If you are self-employed, send copies of your most recent federal tax form with all schedule attachments. Send other proof if you do not have tax forms.)

Employer name, address & phone OR	Amount	How often do	# of hours
Self-employment information	paid	you get paid?	worked per week

4.Do you get any money like the kinds listed below? Yes No

Social Security	Unemployment	Money from friends
Retirement/Pensions/Annuities	Workman’s Compensation	or relatives
Veteran’s Benefits	Interest/Dividends/Royalties	Any other not listed

(Show all money that you get and send proof of the income. You do not have to send proof of Social Security or Unemployment income.)

Income type	Source name,		How much	How often
Income type	address, & phone		do you get?	do you get it?
	address, & phone		do you get?	do you get it?
		$

Have you ever applied for money from any of these sources? Yes No If Yes, when and from which ones?

5.Do you have Medicare or other health insurance? Yes No If Yes, answer the following. (Send proof of coverage and premium payment.)

Insurance company name,	Group/policy number	Monthly		Policy covers:
address, & phone	Group/policy number	cost	hospital		doctor	ambulance
address, & phone		cost	hospital		doctor	ambulance

Can you get health insurance from your employer? Yes No

6.Do you, or you jointly with your spouse, have any assets or resources like those listed below? Yes No If Yes, give us the following information. (Send proof of ownership and value.)

Asset/Resource	Company name, address, & phone;	Value	Amount owed
	Company name, address, & phone;
	Account number and/or description
	Account number and/or description
Checking/Savings accounts (type)		$

Certificates of Deposit		$
Retirement accounts		$
Annuities/Trusts		$
Stocks/Bonds		$
Vehicles (if more than one)		$	$
Property, other than your home		$	$
Other (please be specific)		$	$

7.Did you ever apply for or get Social Security Disability or Supplemental Security Income (SSI)

benefits? Yes No If Yes, when?			Was a decision made? Yes No
If Yes, what was the decision?

8.What is your disability?

Tell us about the doctors or other medical providers who care for you:

Provider’s name(s)

Address & phone of this medical provider

9.Where did you find out about the Medicaid Purchase Plan?

Rights and Responsibilities

I declare that I am a U.S. citizen or in this country legally.

The information I gave on this form is true and correct to the best of my knowledge. I realize if I knowingly give information that is not true OR if I knowingly hold back information, I may get health benefits for which I am not eligible. If that happens, I can be lawfully punished for fraud. I may also have to pay Medicaid back for any medical bills which are paid incorrectly.

I understand that the information I give about my situation will be checked. I agree to help do that, and to let Medicaid get information it needs from government agencies, employers, medical providers, and other sources. If I refuse to help with this process or in later reviews caused by reported changes, or as part of a Recipient Eligibility review, it will mean that I can’t get Medicaid until I do help.

I know that Social Security numbers will only be used to get information from other government agencies to prove my eligibility.

I agree to tell Medicaid within 10 days if 1) I move out of state; 2) there are changes in where I live or get my mail; 3) there are any changes in other health insurance coverage; 4) there is any change in my work status.

By accepting Medicaid, I agree that any medical payments received from other sources will be sent to the Department of Health and Hospitals for any services that were covered by Medicaid.

I can ask for a Fair Hearing if I think the decision made on my case is unfair, incorrect or being made too late.

Medicaid can’t treat me differently because of my race, color, sex, age, disability, religion, nationality or political belief. If I think they have, I can call the U.S. DHHS Regional Office for Civil Rights in Dallas, TX at 1+800+368-1019 or write to Louisiana’s Department of Health & Hospitals, Human Resources at P. O. Box 1349 Baton Rouge, LA 70821-1349.

Signature of Applicant or Authorized Representative		Date

Signature of Agency Representative, if applicable		Date

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Complete the particular areas to fill in the document:

louisiana medicaid paper application fields to complete

Remember to fill in the Tell us who YOU are where YOU, Daytime phone, Tell us about yourself and your, Name first middle initial last, Social Security number, Date of birth Day, Year, Month, Sex MF, Race, US citizen Legal alien, Louisiana resident, Relation to you, Yes No Yes No cid cid cid cid Yes, and self field with the requested information.

step 2 to completing louisiana medicaid paper application

The software will request for additional info to effortlessly fill in the area Employer name address phone OR, Amount paid, How often do you get paid, of hours worked per week, Do you get any money like the, cid InterestDividendsRoyalties cid, cid Money from friends or relatives, cid Unemployment, Income type, Source name address phone, How much do you get, How often do you get it, Have you ever applied for money, and Do you have Medicare or other.

Completing louisiana medicaid paper application stage 3

The Insurance company name address, Grouppolicy number, Monthly cost, Policy covers, hospital, doctor ambulance, cid cid cid, cid cid cid, and Can you get health insurance from section will be your place to include the rights and obligations of each side.

stage 4 to completing louisiana medicaid paper application

Check the areas AssetResource, Company name address phone, Value, Amount owed, CheckingSavings accounts type, Certificates of Deposit, Retirement accounts, AnnuitiesTrusts, StocksBonds, Vehicles if more than one, Property other than your home, Other please be specific, Did you ever apply for or get, What is your disability, and Tell us about the doctors or other and next fill them out.

louisiana medicaid paper application AssetResource, Company name address phone, Value, Amount owed, CheckingSavings accounts type, Certificates of Deposit, Retirement accounts, AnnuitiesTrusts, StocksBonds, Vehicles if more than one, Property other than your home, Other please be specific, Did you ever apply for or get, What is your disability, and Tell us about the doctors or other fields to fill

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Bhsf Form 1 Mpp – Fill Out and Use This PDF

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