Dma 5199 PDF Details

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Question	Answer
Form Name	Dma 5199
Form Length	7 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 45 sec
Other names	dss 5199 form, north carolina dma forms, dma bank account form, dma form get

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Medicaid Renewal Request for Information Notice

COUNTY DEPARTMENT OF SOCIAL SERVICES (DSS)

	Date: _____________________
To: ______________________________________
Address: __________________________________
__________________________________
Case ID No: _______________________________	Worker: ____________________

*THIS FORM MUST BE SENT IN BY ____________________________ (30 DAYS FROM ABOVE DATE) OR YOU MAY LOSE YOUR N.C. MEDICAID OR N.C. HEALTH CHOICE *

Why You Need to Complete This Form

In order to be considered for Medicaid or N.C. Health Choice, you must complete this form. The information will be used to verify that you and your family still qualify. The information is necessary to process your review.

In addition to helping yourself, you can use this form to apply for health insurance coverage for other family members in your house.

Contact __________________ County DSS at ________________ if you have any questions about filling out

this form.

	SECTION 1
	TELL US ABOUT YOURSELF

Do you expect to file a tax return? Yes	No

Are you a dependent on someone else’s tax return? Yes		No

If yes – who?

SECTION 2

TELL US ABOUT YOUR FAMILY

(include family members and tax dependents living in your house)

PERSON 1:

Name:

Does this person expect to file a tax return? Yes No

Does this person expect to be a dependent on someone else’s tax return? Yes No

If yes – who?

Is this person pregnant? Yes No

If so, what is the expected due date?

Does this person have Medicaid? Yes No

DMA-5199 (3/30/16)

If this person does not have Medicaid, complete Attachment A to apply for Medicaid.

PERSON 2:

Name:

Does this person expect to file a tax return? Yes No

Does this person expect to be a dependent on someone else’s tax return? Yes No

If yes – who?

Is this person pregnant? Yes No

If so, what is the expected due date?

Does this person have Medicaid? Yes No

To apply for Medicaid for this person complete Attachment A.

PERSON 3:

Name:

Does this person expect to file a tax return? Yes No

Does this person expect to be a dependent on someone else’s tax return? Yes No

If yes – who?

Is this person pregnant? Yes No

If so, what is the expected due date?

Does this person have Medicaid? Yes No

To apply for Medicaid for this person complete Attachment A.

PERSON 4:

Name

Does this person expect to file a tax return? Yes No

Does this person expect to be a dependent on someone else’s tax return? Yes No

If yes – who?

Is this person pregnant? Yes No

If so, what is the expected due date?

Does this person have Medicaid? Yes No

To apply for Medicaid for this person complete Attachment A.

If more space is needed, please attach a separate sheet.

DMA-5199 (3/30/16)

Medicaid Renewal Request for Information Notice

SECTION 3

TELL US MORE ABOUT THE PEOPLE LISTED ON THIS FORM

A.Income: Does anyone listed on this form have an income? Yes No If yes, complete Attachment B.

B.Living Situation: Does anyone listed on this form live in a:

Long‐term care facility, group home, or nursing home

Private home, but gets at‐home medical, personal or health services

Private home, but gets medical, personal or health services in the community (such as adult day care)

If so, please list their names:

Name(s):

C.Foster Care: Is anyone listed on this form between the ages of 18 and 26 and was in foster care at

age 18? Yes No

If so, please list their names:

Name(s):

SECTION 4

SIGNATURE

I am signing this renewal form under penalty of perjury which means I have provided true answers to all the questions to the best of my knowledge. I know that I may be subject to penalties under federal law if I provide untrue information.

Beneficiary/Authorized Representative*

Date

*The person who completed the form or their legal representative.

	WHERE TO SEND THE INFORMATION

You can complete the form:

• In‐person at the	County DSS Office (street address)

•By phone at:

• By mail at:

County DSS Office, (mailing address)

DMA-5199 (3/30/16)

ATTACHMENT A

TO APPLY FOR MEDICAID FOR ANYONE LISTED IN SECTION 2.

Person 1:

A.Name:

B.Social Security Number:

C.Date of Birth:

D.How is this person related to you?

E.This person is : Male Female

F.This person is a U.S. citizen or U.S. national Yes No

If yes, skip to “additional information” below.

If no, answer question “G”:

G.If this person has eligible immigration status: Document Type:

ID Number:

Check here, if this person has lived in the U.S. since 1996

Check here, if this person, his or her spouse, or a parent is a veteran or an active duty member in the U.S. military

Additional Information

Check here, if this person lives with at least one child under the age of 19 and is the person taking care of this child.

Check here, if this person is 18 years or younger and has a parent living outside of the house

Check here, if this person wants help paying for medical bills from the last three months

Person 2:

A.Name

B.Social Security Number

C.Date of Birth

D.How is this person related to you?

E.This person is : Male Female

F.This person a U.S. citizen or U.S. national Yes No If yes, skip to “additional information” below.

DMA-5199 (3/30/16)

Medicaid Renewal Request for Information Notice

If no, answer question “G”

G.If this person has eligible immigration status: Document Type:

ID Number:

Check here, if this person has lived in the U.S. since 1996

Check here, if this person, his or her spouse, or a parent is a veteran or an active duty member in the U.S. military

Additional Information

Check here, if this person lives with at least one child under the age of 19 and is the person taking care of this child.

Check here, if this person is 18 years or younger and has a parent living outside of the house

Check here, if this person wants help paying for medical bills from the last three months

If more space is needed, please attach a separate sheet.

DMA-5199 (3/30/16)

ATTACHMENT B

INCOME

Person Receiving Income

Income Type *

Amount

Before Taxes

How Often

Received

Start Date

If more space is needed to report changes, attach a separate sheet.

Include income from:

Jobs	Foreign Income	Self‐Employment
Investment Income or Interest	Alimony	Farming or Fishing Income
Unemployment	Rental or Royal Income	Social Security Benefits
Capital Gains	Retirement / Pension	Scholarship
Title	Alien Sponsor	Lump Sum Amount

American Indian / Alaskan Native Income

Do not include:

Child Support

Workers Compensation

Supplemental Security Income (SSI)

Veterans Administration (VA) Benefits

C. Loss of Income: Was anyone listed on this form receiving income in the last 12 months but no longer is?

Yes No

If yes, who, when and what type?

D. Expenses: Is there anyone in the family deducting expenses from their taxes? Yes No If yes, complete Expenses (Deductions) below.

EXPENSES (DEDUCTIONS)

Person Paying Deduction

Deduction Type

Amount

How Often

Start Date

If more space is needed to report changes, please attach a separate sheet.

DMA-5199 (3/30/16)

Medicaid Renewal Request for Information Notice

Allowable deductions include:
Alimony Paid	Health Savings Acct Contributions	Educator Expenses
IRA Contributions	Tuition / Fees	Moving Expenses
Student Loan Interest	Penalty on Early Withdrawals of savings

For those who are self‐employed, allowable deductions also include:

Rent / Royalty Expenses

Certain Business Expenses of Reservists, Performing Artists and Fee Basis Government Officials Deductible Part of Self‐Employment Tax

Domestic Production Activities Deduction Health Insurance Deduction

SEP, SIMPLE and Qualified Plans

E. Health Insurance: Does anyone listed on this form have other health insurance besides Medicaid and

N.C. Health Choice? Yes No

If so, complete Health Insurance below.

HEALTH INSURANCE

Person Covered

Policy Holder

Policy

Number

Insurance Company

Type of

Coverage

Start Date

If more space is needed to report changes, please attach a separate sheet.

Voter Registration:

If you are not registered to vote where you live now, would you like to apply to register to vote here today? __ yes __ no

If you want to register to vote, you can complete a voter registration form at http://www.ncsbe.gov/.

DMA-5199 (3/30/16)

How to Edit Dma 5199 Online for Free

You can easily fill out the dma form get file with our PDF editor. The following steps may help you easily get your document ready.

Step 1: The first task should be to choose the orange "Get Form Now" button.

Step 2: You're now ready to alter dma form get. You've got numerous options with our multifunctional toolbar - you can include, remove, or change the content, highlight its selected parts, and perform several other commands.

Create the dma form get PDF by entering the data needed for each individual part.

example of blanks in dma bank account form

Provide the expected particulars in the field Do you expect to file a tax return, Are you a dependent on someone, If yes who, PERSON, Name, SECTION TELL US ABOUT YOUR FAMILY, Does this person expect to file a, Does this person expect to be a, If yes who, Is this person pregnant Yes No, If so what is the expected due date, and Does this person have Medicaid Yes.

It is essential to put down certain details in the box PERSON, Name, Does this person expect to file a, Does this person expect to be a, If yes who, Is this person pregnant Yes No If, PERSON, Name, Does this person expect to file a, Does this person expect to be a, and If yes who.

The Is this person pregnant Yes No If, PERSON, Name, Does this person expect to file a, Does this person expect to be a, If yes who, Is this person pregnant Yes No, If so what is the expected due date, Does this person have Medicaid Yes, To apply for Medicaid for this, and If more space is needed please field is the place where each party can place their rights and obligations.

part 4 to finishing dma bank account form

End by checking all of these fields and completing the appropriate particulars: SECTION TELL US MORE ABOUT THE, If yes complete Attachment B, B Living Situation Does anyone, cid Longterm care facility group, cid Private home but gets athome, cid Private home but gets medical, day care, If so please list their names, Names, C Foster Care Is anyone listed on, age Yes No, If so please list their names, Names, and SECTION SIGNATURE I am signing.

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