Form Cf Es 2282 PDF Details

Form Cf Es 2282 is a government form used to request information from the IRS about a specific taxpayer. The form can be used to request information such as the taxpayer's name, address, social security number, and other details. It's important to note that the form cannot be used to obtain tax return information. If you need information about a specific tax return, you should use Form 4506-T.

You will discover more details about the form cf es 2282 by looking through the table we prepared.

QuestionAnswer
Form NameForm Cf Es 2282
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesmedicaid medicare buy in application fl form, how to apply for medicaid in florida, apply for florida medicaid, medicaid application florida

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MEDICAID/MEDICARE BUY-IN APPLICATION

Page 1

 

 

 

 

Demographic Information:

 

Please complete all information for you and your spouse. If no spouse, indicate “None”.

 

Your Name (Applicant):

First

 

MI

 

Last

Your Social Security Number:

 

Sex:

Name of Spouse:

 

 

Male

Female

 

First

 

 

 

 

MI

 

Last

 

 

 

Spouse’s Social Security Number (if applying):

 

 

 

 

 

 

 

Sex:

Male

Female

Do you and your spouse live together?

Yes

No

 

 

 

 

 

 

 

Your Medicare claim number:

 

 

 

 

 

 

 

 

 

 

 

 

 

Spouse’s Medicare # (if applying):

 

 

 

 

 

 

 

 

 

 

 

 

 

Living Address: ______________________________________________________________________________________________

Number

Street

Apt #

City

Zip Code

Mailing Address: ______________________________________________________________________________________________

NumberStreetApt #CityZip Code

Telephone Number:

Telephone #

Contact Person:

__________________________________________________________________________

 

(Other than Yourself)

First

Last

 

MI

 

 

______________________________________________________________________________________________

 

Number

Street

Apt #

City

Zip Code

___________________________________

Telephone #

Relationship of Contact Person to you:___________________________________________

Do you want eligibility determined for the

 

 

three months before the month of application?

Yes

No

Technical Information:

Please complete all information for you and your spouse.

Date of Birth:

________________

________________

 

 

 

You

Spouse

 

 

Are you a U.S. Citizen? You:

Spouse:

 

 

 

Yes

No

Yes

No

Date Stamp: (Official DCF use only)

If not a citizen, provide alien number and status: __________________________________ ; __________________________________

You

Spouse (if applying)

Do you intend to remain in the State of Florida? You:

Yes

Do you and/or spouse have any other insurance other than Medicare? If Yes, Complete the following information:

Spouse:

NoYes No

You:

 

Spouse:

 

Yes

No

Yes

No

______________________________________________________________________________________________________________

Name of Other Insurance CompanyOther Insurance Policy Number

______________________________________________________________________________________________________________

Address of Other Insurance Company

Who is Covered by This Insurance

CF-ES 2282, PDF 07/2006

 

BUY-IN APPLICATION

 

 

 

 

 

Page 2

Asset Information: Please list all assets owned by you and/or spouse (even if your spouse is not applying).

TYPE

NAME OF BANK/

ADDRESS

ACCOUNT NUMBER

VALUE OF

IN WHOSE NAME

 

FINANCIAL INSTITUTION

 

 

ASSET

IS IT HELD

CASH

 

 

 

 

 

 

 

 

 

 

 

SAVINGS ACCOUNT

 

 

 

 

 

 

 

 

 

 

 

CHECKING ACCOUNT

 

 

 

 

 

 

 

 

 

 

 

CAR

 

 

 

 

 

Make/Model/Year:

 

 

 

 

 

 

 

 

 

 

 

HOMESTEAD

 

 

 

 

 

 

 

 

 

 

 

OTHER PROPERTY

 

 

 

 

 

 

 

 

 

 

 

TRUST FUND

 

 

 

 

 

 

 

 

 

 

 

STOCKS/BONDS

 

 

 

 

 

 

 

 

 

 

 

TAX SHELTERED

 

 

 

 

 

ACCOUNTS

 

 

 

 

 

LIFE INSURANCE

 

 

 

 

 

 

 

 

 

 

 

KEOGH PLAN

 

 

 

 

 

 

 

 

 

 

 

Other: Please Specify

 

 

 

 

 

 

 

 

 

 

 

Income Information: Please complete all information for you and your spouse (even if spouse is not applying).

Are you or your spouse self-employed?

Applicant

Yes

No

Gross Amount

 

 

Earned Monthly

Spouse

Yes

No

Gross Amount

 

 

Earned Monthly

Do you or your spouse work for someone else?

Applicant

Yes

No

Gross Amount

 

 

Earned Monthly

Spouse

Yes

No

Gross Amount

 

 

Earned Monthly

Do you or your spouse receive income from any of the following?

 

 

Gross Amount Received Each Month

 

 

(Before Any Deductions)

Type

Benefit No.

Applicant

Spouse

Veterans Benefits

 

 

 

Pension

 

 

 

Interest/Dividends

 

 

 

Civil Service Annuity

 

 

 

Income from another person

 

 

 

Black Lung

 

 

 

Social Security

 

 

 

Other (e.g. SSI, Annuities): (specify)

 

 

 

 

 

 

 

CF-ES 2282, PDF 07/2006

BUY-IN APPLICATION

Page 3

YOUR RIGHTS AND RESPONSIBILITIES: Read this sheet before you sign your name.

YOU HAVE THE RIGHT TO:

•Apply for assistance and have a determination of your eligibility made without regard to race, color, sex, age, handicap, religion, national origin, marital status or political belief.

•Have a representative help you fill out the eligibility forms.

•Have action taken on your application promptly and be notified of such action.

•Be informed of other available services of the Department of Children and Families.

•Request a fair hearing when you disagree with a decision of the Department of Children and Families.

•Have the information about you and/or your spouse that is collected by the department treated confidentially in accordance with federal and state laws.

YOU HAVE THE RESPONSIBILITY TO (things you must do):

•Assist in determining your eligibility by giving complete and correct information and provide written proof of information, as requested, within the time limits given.

•Declare the citizenship or alien status for you and your spouse by signing the Medicaid/Medicare Buy-In Application.

•File for any payments or benefits from other sources if this application, or other information, indicates that you or your spouse may be eligible for such payments or benefits.

•Assign your rights to third party benefits and cooperate in reporting any insurance or other health plan that covers medical costs for you (and/or your spouse, if applying) unless good cause can be shown not to do so.

•Report changes in your situation (e.g., income, assets) within 10 days of the change.

•Report your (and your spouse’s, if applying) Social Security numbers. Without accurate numbers, we will be unable to provide Medicaid/Medicare buy-in benefits if you are determined eligible for any benefits.

IMPORTANT INFORMATION ABOUT MEDICAID:

Any person (including the designated representative) who knowingly withholds information or knowingly misrepresents the truth may be punished under federal or state law or both. If you get medical assistance for which you do not qualify, you may have to repay the cash value of that assistance.

Certification of Citizenship/Alien Status: I certify, under the penalty of perjury, by signing my name on this application, that I and my spouse (if applicable) are U.S. citizens or nationals of the United States or qualified aliens.

Certification: In signing this application, I swear and affirm, under penalty of perjury, that the information I have given on this application is correct and complete to the best of my knowledge. I have read and understand the above rights and responsibilities and important information about Medicaid.

Applicant

Go Back To Page 1

 

 

 

 

 

Signature:

 

 

Date:

 

Spouse

 

 

 

 

 

Signature:

 

 

Date:

 

 

 

 

 

 

 

 

 

Designated

 

 

 

 

Representative Signature:

 

 

Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

HELPING PERSON: (Official use only)

 

 

 

 

 

 

 

 

 

Date:

 

 

 

 

 

 

 

 

 

Signature of Individual Who Assisted Applicant in Completing Buy-In Application Form

In accordance with Federal law and our policy, the Department of Children and Families is prohibited from discriminating on the basis of race, color, national origin, sex, age, disability, religion, political belief, or marital status.

CF-ES 2282, PDF 07/2006

How to Edit Form Cf Es 2282 Online for Free

This PDF editor allows you to complete forms. There's no need to do much to update florida medicaid documents. Only consider the next actions.

Step 1: Click the button "Get Form Here".

Step 2: So, you're on the file editing page. You can add content, edit current details, highlight particular words or phrases, place crosses or checks, insert images, sign the template, erase unwanted fields, etc.

These particular sections will help make up the PDF document:

apply for medicaid florida blanks to fill in

Write down the necessary details in Living Address, Number, Street, Apt, City, Zip Code, Mailing Address, Number, Street, Apt, City, Zip Code, Telephone Number, Telephone, and Contact Person Last Other than section.

Entering details in apply for medicaid florida stage 2

You'll be required to write down the information to let the platform fill out the section Are you a US Citizen You, Spouse, Yes, Yes, If not a citizen provide alien, You, Spouse if applying, Do you intend to remain in the, You, Spouse, Yes, Do you andor spouse have any other, You, Yes, and Yes.

Are you a US Citizen You, Spouse, Yes, Yes, If not a citizen provide alien, You, Spouse if applying, Do you intend to remain in the, You, Spouse, Yes, Do you andor spouse have any other, You, Yes, and Yes in apply for medicaid florida

The space NAME OF BANK FINANCIAL INSTITUTION, ADDRESS, ACCOUNT NUMBER, VALUE OF ASSET, IN WHOSE NAME IS IT HELD, TYPE, CASH, SAVINGS ACCOUNT, CHECKING ACCOUNT, CAR, MakeModelYear, HOMESTEAD, OTHER PROPERTY, TRUST FUND, and STOCKSBONDS is going to be where to include each side's rights and responsibilities.

part 4 to filling out apply for medicaid florida

Prepare the form by checking the next areas: LIFE INSURANCE, KEOGH PLAN, Other Please Specify, Income Information Please complete, Applicant, Yes, Gross Amount Earned Monthly, Yes, Gross Amount Earned Monthly, Spouse, Do you or your spouse work for, Applicant, Yes, Gross Amount Earned Monthly, and Yes.

stage 5 to entering details in apply for medicaid florida

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