Georgia Application For Medicaid Form – Fill Out and Use This PDF

Georgia Application For Medicaid Form – Fill Out and Use This PDF

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Georgia Application For Medicaid Form PDF Details

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Georgia Application For Medicaid Form isn’t the one you’re looking for?

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Georgia Application for Medicaid & Medicare Savings for Qualified Beneficiaries

(QMB - payment of premiums, coinsurance, and deductibles;

SLMB - payment of Part B premium; and QI-1 - payment of Part B premium)

INSTRUCTIONS:

1. Read the application carefully & answer each question accurately. Attach additional pages if needed.

2. Sign and mail application to: __________________________ County DFCS

(Mail or deliver application to the DFCS office in your county of residence)

______________________________________

ATTN: ________________________________

3.A telephone interview may be required for these programs. Be sure to enter phone # below.

4.The DFCS Medicaid Specialist will review this application. If it appears that you may be eligible for full Medicaid coverage, the Medicaid Specialist will contact you for more information and verifications.

PERSONAL INFORMATION: You may have someone help you complete this application.

Applicant’s Name (Last, First, Middle Initial)				If you wish to name a person to act on your behalf,
				complete the information below:
				Name (Last, First, Middle Initial)
Mailing Address				Name (Last, First, Middle Initial)
Mailing Address

Street Address				Mailing Address

City	State	Zip		City	State	Zip
Do you own/are you purchasing home?		□ Y	□ N
Phone	County			Phone
E-Mail Address				E-Mail Address
Nursing Facility (if applicable)				Relationship to Individual

COMPLETE THIS INFORMATION FOR YOU AND YOUR SPOUSE.

Name (Self):	Birthdate	Sex	Race	U.S. Citizen	Social Security	Marital
				(Yes or No)	Number	Status
Maiden/other name(s):

Name (Spouse):
Maiden/other name(s):

Are you applying for your spouse, too? □ Yes		□ No
Are you blind or disabled? □ Yes	□ No - Is your spouse blind or disabled? □ Yes □ No

LIVING ARRANGEMENT: Check the box(es) that best describes your current situation.

Living In	Nursing	Another’s	Hospice	Hospital	Katie	Community	Assisted	Other/
Own Home	Facility	Home			Beckett	Care	Living	Renting
	Date			Date		Date
	Admitted:			Admitted:		Admitted:

DHR 700 (R. 05/11)

HEALTH INSURANCE:

Do you have Medicare?		Type of Coverage		Effective Date:	Have you ever
□ Yes	□ No	□ Part A	□ Part B	______________	received SSI?
Are you enrolled in a Medicare		(hospital)	(doctor)		□ Yes	□ No
HMO or Medicare Drug program?		⁭ Part D		Medicare Number:	If so, when did it
□ Yes	□ No	(RX)		____________	end?________


Does your spouse have		Type of Coverage		Effective Date:	Has your spouse
Medicare?	□ No	□ Part A	□ Part B	______________	ever received SSI?
□ Yes		⁭ Part D		Medicare Number:	□ Yes	□ No
					If so, when did it
				____________	end?________

Do you have other health insurance?	□ Yes	□ No
Does your spouse have other health insurance?	□ Yes	□ No

If you answered yes to either of these questions, please complete the following information:

	Health Insurance	Type of Coverage	Effective	Policy
	Company Name,	(Hospital, Medicare	Date	Number
	Address, and Telephone	Supplement, Drugs, Major
	Number	Medical,)
Self

Spouse

Attach copies (front and back) of Medicare and insurance cards if applicable.

REAL PROPERTY: Do you own all or part of any real estate in which you do not live?□ Yes □ No If yes, please complete the following for each piece of real estate. Do not list the house or mobile home in which you live.

Address	Value	Amount Owed

Do you or your spouse own a car, truck, boat, camper, utility trailer, recreational vehicle, etc.?

DHR 700 (R. 05/11)

RESOURCES: Check all resources (assets) owned by you, your spouse, or jointly owned with someone else. Include any accounts or properties on which your name(s) appear. Attach additional pages if necessary.

Do you or your spouse have any of the following resources?

Checking account	□ Yes	□ No	Funeral plans/ prepaid burial item	□ Yes	□ No
Savings account	□ Yes	□ No	Burial plots or contracts	□ Yes	□ No
Government bonds	□ Yes	□ No	Stocks and bonds	□ Yes	□ No
Trust funds	□ Yes	□ No	Other (IRA, CD, promissory note, etc.)	□ Yes	□ No
Have you or your spouse given away any assets for less than its value?				□ Yes	□ No

If you answered yes to any of these questions, describe below. Attach additional pages if necessary.

Type of Resource		Account/ Policy	Value	Name of Bank, Insurance Company,
		Number		Etc.



Do you or your spouse have a life insurance policy?					□ Yes	□ No
If yes, please complete the following information. Attach additional pages if necessary.
Policy Owner	Insurance Company		Policy Number		Face	Cash Value
					Value

INCOME AND EARNINGS: List all types of earnings and income that you and your spouse receives. List the income amount before deductions (such as taxes, insurance, or Medicare premiums) are taken out. Attach additional pages if needed. Income includes, but is not limited to:

Social Security		SSI	Wages/ Self-Employment
Railroad Retirement Benefits		Veterans’ Benefits	Trust or Annuity Payments
Pensions/ Retirement Benefits		Rental Income Paid to You	Oil Royalties/ Mineral Rights
Name of	Type of	Source of Income or Amount	How Often	Claim Number
Person Who	Income	Name of Employer	Received?	(if applicable)
Receives			(weekly,
Income			monthly, etc.)
Income

Are you a veteran? □ Yes □ No Is your spouse a veteran? ⁭ Yes ⁭ No

Where did you and spouse work in the past? ____________________________________________________

Do you or your spouse have any unpaid medical bills ?

□ Yes □ No

DHR 700 (R. 05/11)

PRIVACY STATEMENT:

Federal and state laws and regulations limit the use and disclosure of confidential information concerning applicants and recipients of all agency programs to purposes directly related to the administration of these programs.

ASSIGNMENT OF RIGHTS OF PAYMENT FOR MEDICAL SUPPORT AND OTHER MEDICAL CARE:

(If you are applying on behalf of another individual and do not have the power to execute an assignment for that individual, the individual will need to execute an assignment of the rights described below, as a condition of his or her eligibility for the benefits covered by this application.) As a condition of my eligibility, I agree to assign to the

State all rights to medical support and to payment for medical care from any third party (hospital and medical benefits). I agree to cooperate with the state in identifying and providing information to assist the state in pursuing any third party who may be liable to pay for care and services. I understand that I must report any payments received for medical care within ten days.

APPLICANT’S STATEMENT OF UNDERSTANDING AND AGREEMENT:

I understand that, by signing this application, I am agreeing to a full investigation or review of my eligibility by state and/or federal officials. This may include inquiries of employers, medical providers, financial institutions, and other business and professional persons and review of any agency records. I also agree that my application authorizes these agencies to release to this agency the information needed to determine my eligibility. I agree to provide the documents necessary to establish eligibility. If documents are not available, I agree to give the name of the person or organization from which this agency may obtain the necessary proof.

I understand that each individual who receives assistance must provide or apply for a Social Security Number. I authorize the use of my (our) Social Security Number for such purposes as identification, program reviews or audits, and computer matching with other agencies and institutions such as banks, saving and loan associations, and other government agencies, including Internal Revenue Service, to verify eligibility for assistance.

I understand that my application will be considered without regard to race, color, sex, age, handicap, religion, national origin, or political belief. I understand that I may request a fair hearing if I disagree with an agency decision in my case and that I may be represented by any person I choose.

I understand that Medicaid members who, are an inpatient in a nursing facility, intermediate care facility for

the mentally retarded, or other mental institution that have their medical care paid by Medicaid will be subject to the Medicaid Estate Recovery Program. Additionally, Medicaid members who are 55 years of age or older and who receive home and community based services or are enrolled in and receive services through a waiver program are also subject to Estate Recovery. I acknowledge receipt of a written notice that medical assistance payments made on my behalf may be recovered from my estate after my death.

I certify that I (or if filing for my spouse, my spouse and I) am a U.S. citizen, national, or alien in qualified alien status. If this application is being filed on behalf of another individual or individuals, the actual applicant(s) will need to make this certification.

APPLICANT(S) OR REPRESENTATIVE MUST READ AND SIGN:

State and federal law provide for fine, imprisonment, or both for any person who withholds or gives false information to obtain assistance to which he is not entitled. I understand the questions on this application and I certify, under penalty of perjury, that the information given by me on this form is correct and complete to the best of my knowledge. I agree to notify this agency of changes in my income, resources, or living arrangements, which might affect my right to receive assistance.

Signature of Applicant or Representative:

Date:

Signature of Applicant’s Spouse or Representative:

Date:

DHR 700 (R. 05/11)

DECLARATION OF CITIZENSHIP/IMMIGRATION STATUS

Georgia Department of Human Services

Division of Family and Children Services

I understand that the Georgia Division of Family and Children Services (DFCS) may require verification from the United States Department of Homeland Security (DHS) of my/my children’s citizenship or immigration status when seeking benefits. Information received from DHS may affect my/my children’s eligibility.

Please fill out and sign ONE or BOTH of the following statements as it pertains to the status of each person seeking benefits.

CHILDREN SEEKING BENEFITS

		U.S.	Lawfully	Date Naturalized
		Citizen	Admitted	or Admitted into U.S.
			Immigrant
Name	Place of Birth(city,state,country)	(check whichever applies)		(If applicable)

I, ________________________ attest to the identity of the child/children listed above and

(PRINT NAME)

certify under penalty of perjury, that the information written and checked above is true.

____________________________________		________________________
SIGNATURE (PARENT/GUARDIAN)			(DATE)

	ADULT(S) SEEKING BENEFITS
		U.S.		Lawfully	Date Naturalized
		Citizen		Admitted	or Admitted into U.S.
				Immigrant
Name	Place of Birth(city,state,country)	(check whichever applies)			(If applicable)

I, ________________________ certify under penalty of perjury, that the information

(PRINT NAME)

written and checked above is true.
____________________________________	________________________
SIGNATURE (PARENT/GUARDIAN)	(DATE)
______________________________________________________	_____________________________________
SIGNATURE (PARENT/GUARDIAN)	(DATE)

Form 216 (R. 05/11)

Question	Answer
Form Name	Georgia Application For Medicaid Form
Form Length	5 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 15 sec
Other names	medicaid application for georgia, georgia medicaid qualified beneficiaries, georgia dhr700 medicaid, dhr 700 application form

□ No If yes, please complete the following information about each vehicle. Attach

additional pages if needed.

Amount Owed