Form Dfa Qsq 1 – Fill Out and Use This PDF

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NOTE: If you answered “YES” about assets other than a home or vehicle,

you may use this form to apply for Medicaid, BUT you must be interviewed by a Worker.

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Person(s) Insured

Insurance Company

Policy Number

YES NO

Q Q

1.

I understand by accepting medical assistance under any category, I agree to give back to the State any and all money that is received by anyone listed on this application from an insurance company for repayment of medical and/or hospital bills for which the Medicaid Program has or will make payment. In addition, I agree that all medical payments or medical support paid or owed due to a court order for me or anyone listed on this application must be sent to the State to repay past or current medical expenses paid by the State. This includes insurance settlements resulting from an accident. I further agree to notify the local Department of Health and Human Resources office if I or anyone listed on this application is involved in any accident. I understand that this assignment of funds continues as long as I or anyone listed on this application receives Medicaid.

YES NO

Q Q

2.

I understand it is an eligibility requirement that I must cooperate with the Department of Health and Human Resources and with any provider of medical services in pursuing any resource available to meet the medical expenses of any medical assistance recipient. I agree to assign to the Department benefits available to any medical assistance recipient from any third-party source as a result of injury, accident or illness. I understand that the amount payable to the Department will never exceed the amount of the Medicaid liability. I authorize payment of any such third-party resources directly to the Department. If the liable third-party makes payment directly to me, I agree to refund the Department an amount up to but not exceeding the amount of Medicaid liability. I understand that this repayment must be made even if my eligibility for Medicaid assistance has stopped prior to my receiving such monies. I further authorize the release of any medical information or any information regarding medical insurance to the Department and also authorize the release of any medical insurance information to medical provider(s) for billing purposes. Authorization is also given to the Department to release medical payment information to attorneys and/or insurance companies for the resolution of third-party claims.

YES NO

Q Q

3.I understand that as a recipient of medical assistance, I may be required to cooperate with the Bureau for Child Support Enforcement (BCSE) in child support activities including obtaining medical support.

YES NO

Q Q

4.I understand that I may receive medical assistance for my child(ren), including Early Periodic Screening, Diagnosis, and Treatment (EPSDT).

YES NO

Q Q

16.

I give my permission to the Department of Health and Human Resources to provide information contained in my confidential case record, regarding me or any member of my family or assistance group, to Immigration and Naturalization Services, Social Security Administration, Bureau for Child Support Enforcement, Bureau for Medical Services, Bureau for Public Health, Division of Rehabilitation Services, or any other State or Federal department/agency/organization primarily for the purpose of providing me with access to the services and benefits offered by these departments/agencies/organizations in an efficient manner that allows for coordination rather than duplication of service(s).

YES NO

Q Q

17.

I understand if I give incorrect or false information or if I fail to report changes, then I may be required to repay any benefits I receive. I may also be prosecuted for fraud and I understand that any information given is subject to verification by an authorized representative of the Department. Also, it is understood that any person who obtains or attempts to obtain welfare benefits from the Department by means of a willfully false statement or misrepresentation or by impersonation or any other fraudulent device can be charged with fraud. Punishment upon a conviction may be a fine up to $5,000 and/or a jail sentence of five (5) years in jail.

YES NO

Q Q

18.

I certify that all statements on this form have been read by me or read to me and I understand the questions. I certify that all the information I have given is true and correct and I accept the aforementioned responsibilities.

Applicant’s Signature

Worker’s Signature

Signature of Telephone Interviewer

(Representative Completing Application Form)

Date Signed

Date Signed

Date Signed