Bhsf Form Dra 1 PDF Details

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QuestionAnswer
Form NameBhsf Form Dra 1
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesphotocopies, Supplemental, Spouse, Obsolete

Form Preview Example

BHSF Form DRA-1

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 1-888-342-6207. If you are deaf or hard of hearing, call 1-800-220- 5404.

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)

 

 

 

 

 

 

 

 

 

Social Security Number:

 

 

 

 

Mother’s Name:

 

 

 

 

 

 

 

 

 

Mother’s Maiden Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Place of Birth: City

 

 

 

 

 

 

Parish/County

 

 

State

 

 

Country

 

Do they now have or did they ever get Medicare or Supplemental Security Income (SSI)?

Yes

No

If yes, which one?

Medicare

SSI

 

 

 

 

 

 

 

 

 

Person #2: Name: (first, middle initial, last)

 

 

 

 

 

 

 

 

 

Social Security Number:

 

 

 

 

Mother’s Name:

 

 

 

 

 

 

 

 

 

Mother’s Maiden Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Place of Birth: City

 

 

 

 

 

 

Parish/County

 

 

State

 

 

Country

 

Do they now have or did they ever get Medicare or Supplemental Security Income (SSI)?

Yes

No

If yes, which one?

Medicare

SSI

 

 

 

 

 

 

 

 

 

Person #3: Name: (first, middle initial, last)

 

 

 

 

 

 

 

 

 

Social Security Number:

 

 

 

 

Mother’s Name:

 

 

 

 

 

 

 

 

 

Mother’s Maiden Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Place of Birth: City

 

 

 

 

 

 

Parish/County

 

 

State

 

 

Country

 

Do they now have or did they ever get Medicare or Supplemental Security Income (SSI)?

Yes

No

If yes, which one?

Medicare

SSI

 

 

 

 

 

 

 

 

 

Person #4: Name: (first, middle initial, last)

 

 

 

 

 

 

 

 

 

Social Security Number:

 

 

 

 

Mother’s Name:

 

 

 

 

 

 

 

 

 

Mother’s Maiden Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Place of Birth: City

 

 

 

 

 

 

Parish/County

 

 

State

 

 

Country

 

Do they now have or did they ever get Medicare or Supplemental Security Income (SSI)?

Yes

No

If yes, which one?

Medicare

SSI

 

 

 

 

 

 

 

 

 

Sign your name here

 

 

 

 

 

 

 

 

Date

 

 

 

 

 

Spouse signs here (if applying)

 

Date