Georgia Form Medicaid Application PDF Details

The Georgia Medicaid Application form is a critical step for residents in Georgia who are seeking health coverage through the state’s Medicaid program. This comprehensive form is designed to gather all necessary information to evaluate an individual’s eligibility for Medicaid, without discrimination based on race, color, sex, age, disability, religion, national origin, or political belief. Applicants are urged to provide detailed information regarding their living situation, including but not limited to the number of individuals living in their household who are seeking Medicaid, citizenship status, and the presence of any pregnant women. It also inquires about current health insurance coverage, recent diagnoses of serious conditions such as Breast or Cervical Cancer, and any unpaid medical bills from the past three months, signaling its thoroughness in assessing applicants' needs. Additionally, the form requests details about income, resources, and any dependent care expenses to determine financial eligibility. Importantly, the Georgia Medicaid Application points out that a face-to-face interview is not required, thereby streamlining the process. Nevertheless, for those who find the form challenging, assistance is offered through the Department of Family and Children Services (DFCS) to ensure that no one is barred from applying due to the complexity of the form. Completing this form accurately is paramount, as it includes a declaration under penalty of perjury regarding the applicant’s citizenship status and the accuracy of the information provided. Highlighting a commitment to fair and efficient processing, this form plays a pivotal role in connecting Georgia residents with valuable Medicaid benefits.

QuestionAnswer
Form NameGeorgia Form Medicaid Application
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesonline application for medicaid in georgia, medicaid forms georgia, medicaid forms ga, medicaid application form georgia

Form Preview Example

We will consider this application without regard to race, color, sex, age, disability, religion, national origin or political belief.

Check block(s) that apply to you:

MEDICAID APPLICATION

FOR COUNTY USE ONLY:

Date Received in County Dept

 

Pregnant Woman Families w/Children – LIM

Child(ren) Only – RSM Chafee Independence Program Medicaid

Were you in foster care on your 18th birthday? Yes No In which state?______

PLEASE NOTE: A Face to Face interview is not required for Medicaid applications. Please answer all questions as completely and accurately as possible. If you cannot understand or complete this application, please notify DFCS staff and assistance will be provided free of charge.

Your Name: (Please Print) FIRST

M.I.

 

Last

 

Maiden (if applicable)

 

Today’s Date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address:

 

 

 

 

 

 

 

 

 

City:

 

State:

 

Zip Code:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Residence Address (if different from Mailing Address):

 

 

 

 

 

 

 

Phone Number(s):

E-mail Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please list all persons living with you for whom you want Medicaid. List yourself if you want Medicaid for yourself.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is this

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Person a

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

U.S.

 

Does the

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Citizen?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Father of

Does the

 

 

 

 

 

 

 

 

 

 

 

 

 

(Y/N)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

this child

Mother of

 

 

 

 

 

 

 

 

 

 

 

 

 

(you may

 

 

 

 

 

 

 

 

 

 

 

 

 

 

live in

this child

 

 

 

 

 

 

 

 

 

 

 

 

 

qualify for

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

your

live in your

 

 

 

 

 

 

 

 

 

 

 

 

 

Medicaid

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Suffix

 

 

Sex

 

 

 

Social Security

even if you

 

home?

home?

First Name

MI

Last Name

 

(Jr.)

Race

 

M/F

Date of Birth

Relationship to You

Number

 

answer No)

 

(Y/N)

(Y/N)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Please list all persons living with you for whom you DON’T want Medicaid. List yourself if you don’t want Medicaid. You do not have to provide a SSN or immigration status information for any person who is not asking for Medicaid. If provided, we will use the SSN for computer matches with other agencies and it may help us process your child’s application. We will NOT share your information with the Department of Homeland Security (formerly the INS).

Is anyone in the household pregnant? Yes No If yes, who is pregnant? _________________________ Due Date: ____________ Please attach verification of pregnancy if available.

Do you have any unpaid medical bills from the past three months? Yes

No If yes, which months? _________________________________________________________________

Does anyone in your household have Health Insurance? Yes No

If yes, list Insurance Company and policy number:

Have you or anyone in your household been diagnosed with Breast or Cervical Cancer? Yes No If yes, have you received Women’s Health Medicaid previously? Yes No

Form 94 (11/10)

INCOME, RESOURCES and DAYCARE

List all income received by persons on page 1 of this application. Be sure to show the amount before deductions. Attach an extra sheet if necessary. We will decide, based on the type of Medicaid, whose income must be counted and whose may be excluded. If you are applying for Children Only or Pregnant Woman Medicaid, you do not have to complete the Resources/Vehicles sections below.

 

Gross Amount per Pay

How Often?

 

 

 

 

 

 

Amount in

 

Who Owns

 

Check

(weekly, every 2-weeks,

 

 

 

 

 

 

 

Income

(amount before deductions)

monthly, etc.?)

Name of Person Receiving

 

Resources

 

Account/Value

 

Resource?

Wages/Earnings

 

 

 

 

Cash

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current Employer:

 

 

 

 

Checking Account

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Wages/Earnings

 

 

 

 

Savings Account

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current Employer:

 

 

 

 

Credit Union

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Social Security

 

 

 

 

401K/Retirement

 

 

 

 

 

 

 

Income/SSI

 

 

 

 

Account

 

 

 

 

 

 

 

Worker’s

 

 

 

 

 

 

 

 

 

 

 

 

 

Compensation

 

 

 

 

Other

 

 

 

 

 

 

 

Pensions or

 

 

 

 

Vehicle(s): Cars, trucks, motorcycles (licensed)

Retirement Benefits

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Child Support/

 

 

 

 

Make

 

Model

 

Year

 

Amount

Contributions

 

 

 

 

 

 

 

Owed?

 

 

 

 

 

 

 

 

 

 

 

 

Unemployment

 

 

 

 

 

 

 

 

 

 

 

 

 

Benefits

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Income, please

 

 

 

 

 

 

 

 

 

 

 

 

 

specify:

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you pay for dependent care (daycare for a child or care for an adult who cannot care for himself/herself) so that someone in your household can work?

Name of Parent who works

Name of child or adult cared for

Name of care provider

Amount of Payment

How Often? (weekly, 2-weeks,

monthly, etc)

If you are applying for Medicaid for children and one or both of their parents are not in the home, please provide the following information:

Child’s Name

Absent Parent’s Name (Mother/Father)

Do they have Medical Coverage on the Child?

Yes/No

If Yes to Medical Coverage, please list name

of insurance company & group number

I understand that this information may need to be verified to determine eligibility. I understand wage and salary information supplied by the Georgia Department of Labor may be obtained to verify and determine eligibility for Medicaid. I agree to assign to the state all rights to medical support and third party support payments (hospital and medical benefits). I agree to give the State the right to require an absent parent provide medical insurance, if available. I understand I must get medical support from the absent parent if it is available and must cooperate with the Division of Child Support Services in obtaining this support. If I do not cooperate, I understand I may lose my Medicaid benefits, and only my children will receive benefits unless good cause is established. I understand that I must report changes in my income and circumstances within ten (10) days of becoming aware of the change.

I certify under penalty of perjury that I am a U.S. Citizen and/or lawfully present in the United States. If I am a parent or legal guardian, I certify that the applicant(s) is a U.S. Citizen

and/or lawfully present in the United States. I certify to the best of my knowledge and belief that the person(s) for whom I am applying for Medicaid is/are U.S. citizen(s) or are lawfully present in the United States. I further certify that all of the information provided on this application is true and correct to the best of my knowledge.

Signature (Required): ______________________________________________________________________________

Date: ______________________________

Form 94 (11/10)

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4. The next section comes next with the next few fields to fill out: If you are applying for Medicaid, Childs Name, Absent Parents Name MotherFather, YesNo, If Yes to Medical Coverage please, of insurance company group number, I understand that this information, Date, and Form.

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