Mchp Application Online Form PDF Details

Embarking on the path to securing health coverage for pregnant women and children under the age of 19, the Maryland Children's Health Program (MCHP) application form serves as a critical first step. Designed by the Maryland Department of Health and Mental Hygiene, this form is a gateway for applicants to provide necessary information that determines eligibility for health benefits. Applicants are guided through a series of questions aimed at gathering comprehensive data on household composition, financial situation, and specific healthcare needs. Whether it's a new application or a renewal, the form solicits details such as personal identification, residency, income, and any other health insurance coverages, emphasizing the importance of truthful and complete responses. Beyond aligning with procedural necessities, the form encapsulates a commitment to confidentiality and outlines applicant rights and responsibilities, underscoring Maryland’s dedication to a transparent and fair process. Each section, meticulously crafted, reminds applicants of the underlying objective: to extend crucial health benefits to those in need, ensuring that children and pregnant women receive the care they deserve.

QuestionAnswer
Form NameMchp Application Online Form
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesmd woman renewal online, application mchp online, mchp application, application online mchp

Form Preview Example

NEW APPLICATION

Maryland Department of Health and Mental Hygiene

 

For Office Use Only

‰ RENEWAL APPLICATION

Maryland Children’s Health Program (MCHP)

 

 

FOR PREGNANT WOMEN AND CHILDREN UNDER AGE 19 ONLY

 

Application Instructions:

Complete the application honestly and completely.

Print all answers clearly.

Fill in all boxes. If no answer, write “None” in the box.

DATE STAMP

1.Tell Us Who You Are And Where You Live.

Last Name (Parent/Guardian)

 

First Name

 

M.I (Jr., Sr.)

Home, Work or Cell Phone, or Pager

Family’s Primary Language:

 

 

Marital Status (Circle One):

 

 

 

 

 

 

Number

 

 

 

 

Single, Married, Separated,

 

 

 

 

 

 

 

 

 

 

 

Divorced, or Widowed

 

 

 

 

 

 

 

 

 

 

 

 

Home Address (Include Apartment/Lot Number)

City

 

State

Zip Code

Have you ever used another

 

 

 

 

 

 

 

 

 

 

 

name?

 

 

 

 

 

 

 

 

 

 

 

‰

NO

Mailing Address (If Different From Above)

 

City

 

State

Zip Code

‰

YES

 

 

 

 

 

 

 

 

 

 

 

If Yes, list other names:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

2.Tell Us About the People Living in the Household. Check each child or pregnant woman applying for MCHP.

NOTE: Social Security numbers given will not be shared with the Immigration and Naturalization Service (INS).

 

Are you

 

Last Name

First Name

 

How is this

 

 

Date of

 

 

Sex

 

 

 

Are you

 

Race:

Maryland

 

 

Social Security

 

 

U. S. Citizen?

 

 

applying for

 

 

 

 

person related

 

 

Birth

 

 

Male

 

 

 

of

 

Select all that apply:

Resident

 

 

 

Number

 

 

Yes or No

 

 

MCHP for

 

 

 

 

to you?

 

 

Month

 

 

or

 

 

 

Hispanic or

Caucasian, Asian,

(Permanent

 

 

Needed for

 

 

Needed for

 

 

this person?

 

 

 

 

(Spouse, child,

 

 

Day

 

 

Female

 

 

Latino

 

African-American,

or Indefinitely?

 

 

MCHP

 

 

MCHP

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

applicants only.

 

 

applicants only.

 

 

 

 

 

 

 

 

step-child,

 

 

Year

 

 

 

 

 

 

origin?

 

Amer-Indian

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes or No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Alaskan-Native,

Yes or No

 

 

 

 

 

 

 

 

 

 

 

 

 

grandchild, etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes or No

Native Hawaiian,

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pacific Islander

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

YES

NO

 

 

 

SELF

 

 

 

 

M

F

 

YES

NO

 

YES

NO

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Not applying

 

YES

NO

 

 

 

 

 

 

 

 

 

M

F

 

YES

NO

 

YES

NO

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Not applying

 

YES

NO

 

 

 

 

 

 

 

 

 

M

F

 

YES

NO

 

YES

NO

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Not applying

 

YES

NO

 

 

 

 

 

 

 

 

 

M

F

 

YES

NO

 

YES

NO

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Not applying

 

YES

NO

 

 

 

 

 

 

 

 

 

M

F

 

YES

NO

 

YES NO

 

 

 

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Not applying

3. Is anyone applying for MCHP in your household pregnant?

 

YES

 

NO

 

 

 

 

 

 

 

 

 

 

 

Name of Person Who Is Pregnant

Your Due Date (Required To Process This Application)

Single Baby? Twins? Triplets?

4.Tell Us If Anyone Applying For MCHP (Child or Pregnant Woman) Has Any Unpaid Medical Bills For Services Received In The Three (3) Months Prior to the Month of Application. Examples of unpaid medical bills would include doctor’s visits, hospitalization, medical tests, prescriptions, equipment, etc.

 

 

 

4B. Tell us who received medical care and when.

 

4A. Do you want MCHP to help with these unpaid bills?

YES

NO

Name

Month/Year

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5.Tell Us If Anyone Applying For MCHP Has Other Medical Expenses, for which a third party may be responsible. Fill out the following information if anyone applying for MCHP has medical expenses that are a result of an accident, job injury or malpractice, or is expecting to receive an accident settlement, trust fund, inheritance or other money or property.

Name of Injured Person

Date of Accident/Injury

 

Name and Address of Other Persons or Companies That May Be Responsible

 

 

Money or Property Expected

Name, Address and Telephone No. of Attorney Involved

 

 

6. If The Child Applying For MCHP Is Not Eligible For Free Medical Care

Would you (the parent or guardian of the applicant) be willing to pay $46.00 - $58.00 premium payment each month to cover all children in the household for health insurance

coverage through MCHP Premium?

YES

NO

7A. Does Anyone Applying For MCHP Have Employer-Based Health Insurance?

YES

NO

 

 

If Yes, answer the following:

 

 

 

 

 

 

 

 

Name of Policy Holder ______________________________________________________

Name of Person(s) covered ______________________________________________

 

 

Name

 

 

 

 

 

 

 

Insurance Company Name ___________________________________________________

Policy Number _______________________

 

 

Group#_______________________________

Effective Date ___________________________

End Date _______________________________

 

 

7B. Have you dropped employer-based health insurance coverage for the applicant within 12 months of filing this application for MCHP?

 

YES

NO

 

 

 

 

 

 

 

 

If yes, please tell us when and why coverage was dropped:

0-3 months

4-6 months

7-9 months

10-12 months

 

 

Changed Employer

Terminated From Job

Employer dropped coverage

 

COBRA Coverage Ended

No Longer Needed

Quit Job

Cost

Moved Out of Service Area Of Employer’s Health Plans

Dropped Limited Benefit Insurance (Vision, Dental, Not Hospital)

Other: ______________

 

 

 

 

 

 

 

 

 

 

8.Tell Us About Family Income.

A. Earned Income. List any wages, tips, commissions, earnings or money from self-employment. Send proof of income if you did not give Social Security numbers in Question 2. For child applicants, we count the parents’ income for children if living together. We count income from your child’s brothers and sisters living in the house- hold if you choose to include them. For pregnant women of any age, we count the pregnant woman’s income and the income of her spouse, if married and living together.

We don’t count income from other adults in the household (grandparents, aunts, and uncles).

Name of Employed

Person

Name of Employer

Address of Employer

Street, City, State, Zip Code

Telephone

Number

Gross Amount Paid

(before taxes)

Each Pay Period

How Often Paid?

weekly

biweekly

monthly

2x monthly

quarterly

annually

Job

Start Date

Job

End Date

Student

Status

(Full or

part-time)

B. Unearned Income. List any other income received such as alimony, child support, pension, Social Security, income received from renting property to others and benefits (retirement, strike benefits, unemployment, veterans, workers compensation). Include out-of-state benefits.

Person Receiving Income

Type (For Benefits, Include Claimant ID #)

Gross Amount Received

How Often?

 

 

 

 

 

 

 

 

C . If you didn’t list any income in 8A. or 8B., how do you get food and shelter?_________________________________________________________________________

9A. Tell Us If You Pay For Child Care While You Are Working. This expense lowers the amount of income we count and may help you become eligible.

Name of Child Care Provider or Day Care Center

 

Telephone #

 

Name(s) of Child(ren) Cared For

 

Your Cost

 

 

Who Pays For This Child?

 

 

 

 

 

 

 

 

 

$

PER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

PER

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you have Purchase of Care Services/Vouchers through the Department of Social Services?

YES

NO

 

 

 

 

 

9B. Tell Us If You Pay Child Support Or Alimony. These expenses lower the amount of income we count and may help you become eligible.

 

 

 

Name of Person In Your Household Who Is Paying

 

Name of Person Outside Your Household Who Is

 

Amount Paid

 

 

 

How Often?

 

Child Support or Alimony

 

 

Receiving These Payments

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

10. Other Information

 

 

 

 

 

 

 

 

 

 

 

 

 

The Maryland Children’s Health Program would like to know how you found out about

If anyone in your household is not registered to vote, would they be interested in

our program.

 

 

 

 

 

receiving voter registration forms?

YES

NO

How Many?_______

Friend

Family

School

Community Organization

 

 

 

 

ALREADY REGISTERED

Doctor/Health Care Professional

Advertisement

Other _________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

--GO TO NEXT PAGE TO SIGN APPLICATION—

Here are your rights and responsibilities under the Maryland Children’s Health Program.

Please read these carefully before signing below.

Health Care Benefits I know I have the right to request and, if found eligible, to receive MCHP benefits based on policies and standards established under Maryland law. If I am applying as a pregnant woman, I understand that abortion is not covered.

Confidentiality I understand that the information I have given is confidential. I agree that medical information about my children or me can be released when the law allows.

Social Security Number (SSN) I understand that providing the SSNs of MCHP applicants is required and that providing the social security numbers of other household members and MCHP Premium applicants is voluntary. I will not be penalized if the SSNs of household members who are not applying for MCHP or the SSNs of MCHP Premium applicants are not provided. SSNs will not be shared with Immigration and Naturalization Services (INS), and will only be used to help check the information about income and insurance coverage and to help maintain eligibility files. If I do not have a SSN and want to apply for one, I understand that my case manager will help me.

Personal and Financial Information I agree to the release of personal and financial information from this application form to the agencies determining eligibility. I give permission for officials of the Maryland Children’s Health Program to verify all information on this form. I understand I may be asked to provide additional information.

Third Party Payments And Cooperation With Quality Control Review I understand that I am required by law to assign to the State all rights to medical support and other third party payments (hospital and medical benefits) and to cooperate with the State’s Medical Assistance quality control review process including verification of all information pertinent to the determination of eligibility.

Reporting Changes I have a responsibility to report all changes that might affect eligibility within ten (10) days of the change. Examples of changes I must report are changes in number of people in the household, address, income, employment and pregnancy. I can report changes in person, by telephone, or by mail to my case manager at my local health department or at the Department of Health and Mental Hygiene.

Rights I know that this application will be considered without regard to race, color, sex, age, handicap, religion,

national origin or political belief. I know that I may request a hearing if I believe the State of Maryland in processing my application has made an error or if I feel I have been discriminated against. I have the right to appeal any action taken by the Department. If I ask for a hearing, my case manager can help me put my request in writing. At my hearing, I can speak for myself or have someone else represent me. I have a right to a written notice of all decisions affecting my eligibility.

Please sign this statement.

I certify that the information I have provided above is true to the best of my knowledge and I give permission for the State of Maryland to make any necessary contacts to check my statements. I have read the list of my rights and responsibilities. I know that I can be penalized if I knowingly give false information. I certify that the children and pregnant woman for whom I am applying are U.S. citizens or lawful immigrants or are applying for emergency services only.

This application must be signed by a pregnant or post-partum woman of any age, a parent or step-parent living with the child applicant, or an authorized representative aged 21 or over for a child not living with a parent.

Signature:

 

Date: ______

_________________

 

 

 

 

 

PLEASE PRINT NAME