Mchp Application Online Form – Fill Out and Use This PDF

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: ______________

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