Form W 1Qmb PDF Details

The W-1QMB form, issued by the State of Connecticut Department of Social Services, serves as a pivotal document for individuals seeking to apply or redetermine their eligibility for Medicare Savings Programs, including the Qualified Medicare Beneficiary (QMB), Specified Low-Income Medicare Beneficiary (SLMB), and Additional Low-Income Medicare Beneficiary (ALMB) programs. It begins with queries about the need for special accommodations due to disabilities, emphasizing the department's commitment to accessibility. Applicants are required to provide personal details such as name, contact information, marital status, and intricate details regarding Medicare coverage. The form also respects privacy in matters of race and ethnic origin while facilitating compliance with federal civil rights laws. Citizenship status, sources of income, and consent for verification of non-citizen status with the United States Citizenship and Immigration Services (USCIS) form other crucial segments, ensuring a comprehensive evaluation for eligibility. Furthermore, applicants must disclose their income details transparently to assess qualification accurately. The form underscores the confidentiality of the provided information, its use solely for program administration, necessary consent for information sharing within federal and state guidelines, and the penalties for providing false statements, highlighting the seriousness and the importance of accuracy in the application process. Additionally, it informs applicants about their rights and the procedures for requesting reasonable accommodations or raising complaints regarding discrimination, projecting a structure that is both inclusive and vigilant about applicants' rights and welfare.

QuestionAnswer
Form NameForm W 1Qmb
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesstate of ct form w 1qmbr, Alaska, W-1QMB, how much is the cost of 1qmb

Form Preview Example

State of Connecticut

Department of Social Services

W-1QMB (Rev. 10/09)

Medicare Savings Programs Application/Redetermination

(QMB, SLMB, ALMB)

Do you need a reasonable accommodation or special help to complete your application/redetermination because

you have a disability? Yes No If you checked yes, please see page 3 about how we can help. If you need a reasonable accommodation or special help, what kind of help do you need?

Please give us the following information about you:

Your Name:

First

M.I.

Last

Your Address:

Your Mailing Address (if different):

 

 

 

Your Telephone Number:

 

 

 

A Message Number:

Your Marital Status:

Never Married

Married

Separated

This application is for

Yourself only

Yourself and your spouse

Your Spouse’s Name:

 

 

 

 

Divorced

Widowed

 

 

First

 

M.I.

 

 

Last

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you have Medicare?

 

 

 

 

 

Social Security

 

 

 

Part A?

 

 

Part B?

 

 

Date of Birth

Place of Birth

 

Number

 

Sex

 

(check one)

 

(check one)

Yourself

 

 

 

 

 

 

 

Yes

No

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

Your

 

 

 

 

 

 

 

 

 

 

 

 

Spouse

 

 

 

 

 

 

 

Yes

No

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

You are not required to provide race or ethnic origin information, however, your cooperation will help determine compliance with the federal civil rights law. If you do not wish to give this information, it will in no way affect consideration of your application. We are authorized to ask for this information under Title VI of the Civil Rights Act of 1964.

Are you Hispanic or Latino?

Yes

What is your racial origin? (check all that apply)

Native American or Alaska Native

No

Asian

White

Black or African Descent

Native Hawaiian or Other Pacific Islander

Please give us information about your citizenship:

 

 

 

If no, what is your

 

 

 

 

 

 

 

non-citizen status?

What is your

 

What are the

What is your

 

Are you a U.S.

(refugee,

alien

What is your

date and place

sponsor’s

 

citizen?

 

permanent

registration

country of

that you came

name? (if

 

(check one)

resident, etc.)

number?

origin?

into the country?

appropriate)

Yourself

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

Your

 

 

 

 

 

 

 

Spouse

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

Please give us information about your Income:

Please list all income that you and your spouse receive. Please list the amounts of income before any deductions are made. Examples of income are Social Security, Supplemental Security Income (SSI), wages, pensions, disability benefits, worker’s compensation, unemployment compensation, interest, dividends, rental property income, alimony and child support.

 

Income for Yourself

 

Income for Your Spouse

Name and Address of Employer, if any:

 

Name and Address of Employer, if any:

 

 

 

 

 

 

 

 

 

Name of Pension Company:

 

Name of Pension Company:

 

 

 

 

 

 

 

 

 

 

 

 

How often do

 

 

 

How often do

Where does the

How much do

 

you receive it?

Where does the

How much do

 

you receive it?

money come

you receive?

 

(Weekly,

money come

you receive?

 

(Weekly,

from?

 

 

Monthly or

from?

 

 

Monthly or

 

 

 

Quarterly)

 

 

 

Quarterly)

Social Security

$

 

 

Social Security

$

 

 

 

 

 

 

 

 

 

 

SSI

$

 

 

SSI

$

 

 

 

 

 

 

 

 

 

 

Pension

$

 

 

Pension

$

 

 

 

 

 

 

 

 

 

 

Wages

$

 

 

Wages

$

 

 

 

 

 

 

 

 

 

 

Other

 

 

 

Other

 

 

 

(describe):

$

 

 

(describe):

$

 

 

 

 

 

 

 

 

 

 

Other

 

 

 

Other

 

 

 

(describe):

$

 

 

(describe):

$

 

 

 

 

 

 

 

 

 

 

I authorize the Department of Social Services to verify any information regarding anyone’s non-citizen status with the United States Citizenship and Immigration Services (USCIS). I understand that the department will not share the information given on this form with USCIS. I also understand that USCIS cannot use this application to deny admission to the U.S., harm permanent resident status or deport me.

I give the Department of Social Services permission to share my name and other information with programs that help with energy costs for my home. These programs will use this information only to decide if I qualify for these benefits and to offer me the benefits.

I certify that all the statements made on this form are true and complete to the best of my knowledge. If I have knowingly given incorrect information, I may be subject to the penalties for false statements as specified in Connecticut General Statute Sections 53a-157b and 17b-97 and to penalties for larceny as specified in sections 53a-122 and 53a-123. I may also be subject to penalties for perjury under federal law.

Signature of Applicant

Date

Signature of Spouse

Date

 

 

 

 

Signature of Conservator or Other Representative

Date

 

 

This information is available in alternate formats. Phone (800) 842-1508 OR TDD/TTY (800) 842-4524.

2

If you need a reasonable accommodation or special help:

If you cannot do something we ask you to do because you have a disability, you may request a reasonable accommodation or special help. We can use different methods to complete your application or redetermination. For example, we may be able to complete your application or redetermination over the telephone if you cannot come into the office, we may be able to help you get certain proofs, or give you extra time to provide information. Contact your local regional office to request a reasonable accommodation or special help. If we do not agree to give you a reasonable accommodation or special help, you can complain to the department’s Americans with Disabilities Act (ADA) coordinator. See the bottom of this page for how to make a complaint.

Important information for you to know about your application/redetermination:

•This application/redetermination is a request for help from the Medicare Savings Programs only.

•All the information given on this form is confidential and will only be used to administer the programs except for certain exceptions.

•The Social Security numbers of everyone receiving or requesting assistance will be used to verify identity and eligibility. Social Security numbers will also be matched against federal, state and local government files by computer. The department is allowed to request Social Security numbers based on the following statutes: for Medicaid, 42 USC sections 1320b-7(a)(1), (b)(2) and Connecticut General Statutes section 17b-77.

•The department will request information through the Income and Eligibility Verification System (IEVS). The information will be used to process this application/redetermination. Information will come from certain State and Federal agencies when allowed by law. We may directly verify information we receive with other sources such as banks and employers. Results from such verification may affect eligibility.

In accordance with Federal law and U.S. Department of Health and Human Services (HHS) policy, the Department of Social Services is prohibited from discriminating on the basis of race, color, national origin, sex, age or disability. To file a complaint of discrimination, write HHS, Director, Office for Civil Rights, 200 Independence Avenue, S.W., Room 509-F, HHH Building, Washington, D.C. 20201 or call (202) 619-0403 (voice) or (202) 619-3257 (TTY).

Under state law you have the right to make a discrimination complaint if you think we have taken actions against you because of your race, color, religious creed, sex, marital status, age, national origin, ancestry, criminal record, political beliefs, sexual orientation, mental retardation, mental disability, learning disability or physical disability, including but not limited to blindness. You or someone representing you may write to or call one or more of these agencies to make a discrimination complaint: Commissioner of the Department of Social Services, Attention Affirmative Action Division Director/ADA Coordinator, 25 Sigourney Street, Hartford, CT 06106-5033, or call 1-860-424-5040 (TDD: 1-800-842-4524); Connecticut Commission on Human Rights and Opportunities, 21 Grand Street, Hartford, CT 06106, or call 1-860-541-3400 (TDD: 1-860-541-3459).

3

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