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Question | Answer |
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Form Name | Bhsf Form Dra 1 |
Form Length | 1 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 15 sec |
Other names | photocopies, Supplemental, Spouse, Obsolete |
BHSF Form
Rev. 2/07
Prior Issue Obsolete
Louisiana Medicaid – U.S. Citizen Information Form
1.Please read the flyer “Important News from Louisiana Medicaid” that came with this form.
2.Fill out and sign this form. If more space is needed, use another sheet of paper.
3.Get this form to us right away. Mail, fax, or take this form to your local Medicaid office. If you need the address or fax number, call
If you choose to mail original proof of citizenship and/or identity, you do so at your own risk. Originals will be mailed back to you. We also accept photocopies.
Please give us the following information about each person who gets or is applying for Medicaid.
Person #1: Name: (first, middle initial, last) |
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Social Security Number: |
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Mother’s Name: |
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Mother’s Maiden Name: |
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Place of Birth: City |
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Do they now have or did they ever get Medicare or Supplemental Security Income (SSI)? |
Yes |
No |
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If yes, which one? |
Medicare |
SSI |
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Person #2: Name: (first, middle initial, last) |
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Social Security Number: |
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Mother’s Name: |
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Mother’s Maiden Name: |
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Place of Birth: City |
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Do they now have or did they ever get Medicare or Supplemental Security Income (SSI)? |
Yes |
No |
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If yes, which one? |
Medicare |
SSI |
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Person #3: Name: (first, middle initial, last) |
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Social Security Number: |
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Mother’s Name: |
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Mother’s Maiden Name: |
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Place of Birth: City |
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Do they now have or did they ever get Medicare or Supplemental Security Income (SSI)? |
Yes |
No |
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If yes, which one? |
Medicare |
SSI |
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Person #4: Name: (first, middle initial, last) |
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Social Security Number: |
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Mother’s Name: |
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Mother’s Maiden Name: |
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Place of Birth: City |
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Do they now have or did they ever get Medicare or Supplemental Security Income (SSI)? |
Yes |
No |
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If yes, which one? |
Medicare |
SSI |
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Sign your name here |
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Date |
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Spouse signs here (if applying) |
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Date |