Lamoms Medicaid Form – Fill Out and Use This PDF

4.What is your best guess of your due date?

Are you expecting more than one baby?  Yes  No

5.Give us information about your legal husband who lives with you. If you are under age 18,

list your parents who live with you.  None – Go to Question 6 Do not list step-parents.

Person #1

Name							 Male  Female
		FIRST		MIDDLE INITIAL	LAST
Date of Birth					Social Security Number
		Month	Day	Year

Race/Ethnic Background (Optional - you may mark one or more):  White  Black  Hispanic or Latino

Asian  American Indian or Alaska Native  Native Hawaiian or Pacific Islander Relationship to You:  Husband  Parent

Person #2
Name							 Male  Female
		FIRST		MIDDLE INITIAL	LAST
Date of Birth					Social Security Number
		Month	Day	Year

Race/Ethnic Background (Optional - you may mark one or more):  White  Black  Hispanic or Latino

 Asian  American Indian or Alaska Native  Native Hawaiian or Pacific Islander Relationship to You:  Husband  Parent

6.List ALL children under age 19 who live with you.  None – Go to Question 7

If you are under age 18, list your brothers and sisters under age 19. If there are more than 4 children, use a separate sheet of paper.

A. Name							 Male  Female
		FIRST		MIDDLE INITIAL	LAST
Date of Birth					Social Security Number
		Month	Day	Year

Race/Ethnic Background (Optional - you may mark one or more):  White  Black  Hispanic or Latino

Asian  American Indian or Alaska Native  Native Hawaiian or Pacific Islander Relationship to You:  Child  Stepchild  Brother/Sister  Other:

B. Name							 Male  Female
		FIRST		MIDDLE INITIAL	LAST
Date of Birth					Social Security Number
		Month	Day	Year

Race/Ethnic Background (Optional - you may mark one or more):  White  Black  Hispanic or Latino

Asian  American Indian or Alaska Native  Native Hawaiian or Pacific Islander Relationship to You:  Child  Stepchild  Brother/Sister  Other:

C. Name							 Male  Female
		FIRST		MIDDLE INITIAL	LAST
Date of Birth					Social Security Number
		Month	Day	Year

Race/Ethnic Background (Optional - you may mark one or more):  White  Black  Hispanic or Latino

Asian  American Indian or Alaska Native  Native Hawaiian or Pacific Islander Relationship to You:  Child  Stepchild  Brother/Sister  Other:

D. Name							 Male  Female
		FIRST		MIDDLE INITIAL	LAST
Date of Birth					Social Security Number
		Month	Day	Year

Race/Ethnic Background (Optional - you may mark one or more):  White  Black  Hispanic or Latino

Asian  American Indian or Alaska Native  Native Hawaiian or Pacific Islander Relationship to You:  Child  Stepchild  Brother/Sister  Other:

2

7. Is anyone working?  Yes – Fill Out Below  No – Go to Question 8

Tell us about wages or cash received from working, self-employment, and tips for you and your husband. If you are under age 19, tell us your parents’ information (not step-parents).

Who works?	Employer’s Name	How much is received (show Is insurance offered?
		gross, not take home pay)?

			 Yes  No
	Employer’s Phone Number	$ ___________________
		How often?
		 weekly  every 2 weeks
	 Self-employed
		 twice a month  monthly
Who works?	Employer’s Name	How much is received (show Is insurance offered?
		gross, not take home pay)?
			 Yes  No
	Employer’s Phone Number	$ ___________________
		How often?
		 weekly  every 2 weeks
	 Self-employed
		 twice a month  monthly

8.Are you on maternity leave from your job?  Yes  No

9.Does anyone get money that is not from a job like the kinds listed below?

Social Security SSI Unemployment Worker’s Comp	Money from Friends/Relatives
Child Support (list the child as the person who gets it) Alimony	Something else (list below)

Yes – Fill Out Below  No – Go to Question 10

Tell us about income for you and your husband. If you are under age 19, tell us about your parent’s income (not step-parents).

Who gets it?	What is it?	How much?	How often?
			 weekly  every 2 weeks
		$___________________	 twice a month	 monthly
Who gets it?	What is it?	How much?	How often?
			 weekly  every 2 weeks
		$___________________	 twice a month	 monthly
Who gets it?	What is it?	How much?	How often?
			 weekly  every 2 weeks
		$___________________	 twice a month	 monthly
Who gets it?	What is it?	How much?	How often?
			 weekly  every 2 weeks
		$___________________	 twice a month	 monthly

10.Do you have health insurance?  Yes – Fill Out Below  No – Go to Question 11

Policyholder’s Name						Coverage Start Date
Insurance Name and Phone Number
Policy Number					Group Number
What does it cover? (check all that apply)  Hospital				 Doctor  Medicine  Dental  Ambulance
 Pregnancy  Family Planning

Is this policy through a job?  Yes  No If yes, name of employer:

11.Will you have the option to get insurance for your newborn?  Yes  No

12.Do you need Medicaid for any of the last 3 months to cover medical bills (paid or unpaid) for

these months?  Yes – Fill Out Below  No – Go to Question 13

Which months?

3

13.Does anyone pay for child care or care for an adult with a disability in order to work or get training?  Yes – Fill Out Below  No – Go to Question 14

Name of Person Who Gets Care

Who pays for the care?

How much is paid?					How often paid?
Is any help received with paying it?				 Yes – How much?					 No
Name of Day Care or Caregiver
Phone Number (		)

14.Does anyone in your home pay court-ordered child support or alimony?  Yes – Fill Out Below  No – Go to Question 15

Name of Person Who Pays It

How much is paid?

How often paid?

15.Have you ever received LaMOMS or Medicaid in Louisiana?  Yes – Answer the Question Below  No – Go to Question 16

If you still have your plastic Medicaid card, you can use the same card if you qualify again. We will not send a new card unless you tell us to.

Will you need a new plastic Medicaid card?  Yes  No

16.Have you ever received Supplemental Security Income (SSI)?  Yes  No

17.Do you have or have you ever received Medicare?  Yes  No

The Medicare card looks like this.

This is the end of the application.

SIGN BELOW

By signing this application I am giving my permission to the State of Louisiana and its agents to make contacts to verify the information given on this application. Under penalty of perjury I certify all information I have given is true. I state that I have received and read the Rights and Responsibilities on the next page.

Sign Your Name Here:

Date:

Send Your Completed Application to:

LaMOMS

P.O. Box 91278

Baton Rouge, LA 70821-9278

FAX: 1-877-523-2987

4

YOUR RIGHTS AND RESPONSIBILITIES

Keep this page for your records.

WHAT MEDICAID HAS THE RIGHT TO EXPECT OF YOU

CITIZENSHIP AND IMMIGRATION STATUS: You state that the information about citizenship and immigration status given at the beginning of this application form is true and correct.

REPORTING THE TRUTH: You state that the information you give on the application form is true and correct. You understand if you purposely give information that is not true OR if you purposely do not tell information that you are supposed to, you may get health benefits that you should not get. If that happens, you can by law be punished for fraud. Also, you may have to pay money back to Medicaid for the bills it paid by mistake.

VERIFICATION OF INFORMATION: You understand that the information you give about yourself will be checked. You agree to help do that and let Medicaid get information it needs from government agencies, employers, medical providers, and others.

SOCIAL SECURITY NUMBERS: You understand Social Security numbers will only be used to get information from other government agencies to make a decision on your eligibility for Medicaid.

PAYMENT OF MEDICAL CARE BY A THIRD PARTY: By accepting Medicaid, you understand that the Department has the right to get money received by you from other sources like insurance payments or lawsuit settlements for services that Medicaid has paid for you.

REPORTING CHANGES: You agree to tell Medicaid within 10 days: 1) if you move out of state; 2) there is a change in your mailing or home address; and 3) there is any change in your health insurance and premiums. CHILD SUPPORT ENFORCEMENT: You understand that Medicaid will send case information to Child Support Enforcement for medical support only if you ask them to.

WHAT YOU HAVE THE RIGHT TO EXPECT FROM MEDICAID

RIGHT TO A FAIR HEARING: You understand that you may ask for a Fair Hearing if you think any decision made on your case is unfair, incorrect, or made too late.

NO DISCRIMINATION: You understand Medicaid cannot treat you differently because of race, color, sex,

age, disability, religion, nationality, or political belief. If you think it has, you can call the U.S. DHHS Regional Office for Civil Rights in Dallas, TX at 1-800-368-1019 or write to Louisiana’s Department of Health &

Hospitals, Human Resources at P. O. Box 4818 Baton Rouge, LA 70821-4818.

OTHER SERVICES: You understand that information about WIC, KIDMED, and other Medicaid services will be sent to you if you are eligible for Medicaid.

Documents of Proof You May Need to Send Us

If any of these things apply to you and your family, send copies of these documents.

Let us know if you cannot get them. We may be able to help.

Copies of your health insurance cards (front and back).

If you are not a U.S. citizen, send a copy of your Permanent Resident Card (green card) or other form from U.S. Citizenship and Immigration Services.

If you were not born in Louisiana, send proof of U.S. Citizenship such as a birth certificate, souvenir birth certificate, U.S. Passport, or adoption papers. If you don’t have any of these things, ask us about other things

you can use.

Proof of income received by you, your husband, and if you are under age 19, your parents who live with you.

Send pay stubs from last month showing gross pay (before taxes), a letter from the employer, if self-employed send copies of last year’s tax return and all schedule attachments. Examples of proof for any income not

received from working would be award letters, or letters from the friend or relative who is giving you or your family money.

Proof of child care payments from the day care center. Proof of payments for adult care from the caregiver.

Court order and proof of alimony or child support payments made to persons outside the home. If it is paid through Louisiana Support Enforcement Services (SES), you DO NOT have to send proof – let us know.

If you are requesting LaMOMS/Medicaid coverage for the three months before you apply, send proof of income for those months.

5

IMPORTANT PHONE NUMBERS

					PHONE NUMBER			TTY TEXT
								TELEPHONE
		LaMOMS		1-888-342-6207			1-800-220-5404
		EPSDT (prenatal clinics, family planning, helps			1-800-359-2122			1-877-544-9544
		with finding a Primary Care Doctor)
		CommunityCARE (to request a change of		1-800-259-4444			1-877-544-9544
		Primary Care Doctor)
		Physician Referral Assistance			1-877-455-9955
		Medicaid Services		1-888-342-6207
		Dental Program			1-800-251-2229
		Transportation (to request non-emergency		1-800-259-1944
		transportation – call at least 48 hours in advance)
		24 Hour Nurses Hotline (CommunityCARE)			1-866-529-1681
		Replace Medicaid Card		1-800-834-3333

IMPORTANT WEB SITES

		LaMOMS – Medicaid for Pregnant Women			www.LaMOMS.DHH.Louisiana.gov
		LaCHIP – Medicaid for Children			www.LaCHIP.org
		Other Medicaid Programs			www.Medicaid.DHH.Louisiana.gov
		Find a Doctor Who Accepts Medicaid			www.La-CommunityCare.com
		KIDMED & CommunityCARE			www.La-KidMed.com
		Apply for or Renew Medicaid			www.Medicaid.DHH.Louisiana.gov

KEEP THIS PAGE FOR YOUR RECORDS

6