If you are applying for Medicaid, it is important to understand the Form 284 process. The form serves as an essential step in the application process, and will have a direct impact on your coverage eligibility. In this blog post, we'll explore what Form 284 is, who needs to complete it, when it should be completed, and how you go about completing the form accurately so that your Medicaid application can be approved swiftly and successfully.
| Question | Answer |
|---|---|
| Form Name | Medicaid Form 284 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | 5.4.2_Form_284_ Newborn_Certifi cation_8 10 form 284 fillable |
NEWBORN CERTIFICATION
Alabama Medicaid Agency
Attn: Certification Support
501 Dexter Avenue
P.O. Box 5624
Montgomery, AL
Name and Address of Mother |
|
______________________________________ |
Agency/Hospital:_________________________ |
______________________________________ |
Contact Person:__________________________ |
______________________________________ |
Contact Phone #:_________________________ |
______________________________________ |
Fax #:__________________________________ |
RE: Medicaid Coverage for Newborn Children of Medicaid Eligible Mothers (Including SSI Mothers)
Medicaid is available to certain children born to mothers eligible for and receiving Medicaid at the time of the child's birth. The child may be eligible for Medicaid up to age one.
In order to have Medicaid pay claims for the child, please answer the following questions and return this letter in the
Please print your responses to the following questions:
1.What is the name of the child? ____________________________________________________
2. |
What is the sex of the child? ________ Male ________ Female |
3.What is the date of birth of the child? _______________________________________________
4.If the child has a Social Security Number, please list the number: _________________________
5. |
Does/will the child live in the home with the mother? ________Yes |
________No |
6. |
Will the child require additional days in the hospital? ________Yes |
________No |
7.Mother’s Signature _____________________________________________________________
8.Mother’s Social Security Number __________________________________________________
9.Mother’s daytime telephone number, including area code (_________) ____________________
10. |
Does the mother receive SSI? ________Yes ________No |
Please remember that the above information is needed in order to pay medical bills for the child up to age one. The Medicaid card must be presented to the provider of medical services in order for payment to be made. If the child does not have a Social Security number yet, please notify Medicaid as soon as you have your child’s Social Security number.
Form 284 (Revised 02/2007) |
Alabama Medicaid Agency |
NEWBORN CERTIFICATION
(Form 284 Instructions)
Purpose: |
To enroll children of Medicaid Eligible mothers in Medicaid from birth until their |
|
first birthday. |
Distribution: |
Original - Medicaid Central Office case file. |
Instructions:
This form may be completed by the mother of the child, by an employee of the hospital where the child is born or by someone else, such as an employee of a public agency or other representative of the mother. The mother must sign the form at item 7.
Name and Address of Mother (block at top left). Enter the name and address of the mother in this block.
Agency/Hospital, Contact Person, Contact Phone Number, Contact Fax Number (top right). Enter the name of the hospital or agency (if applicable), a contact person, the contact’s phone number and the contact’s fax number (if applicable.
1.Enter name of the child.
2.Indicate with an “X” the sex of the child.
3.Enter the date of birth of the child.
4.List the child’s Social Security number. If not available, the mother should apply through Social Security for the number. The mother should notify the Medicaid agency immediately when the number is received by calling the telephone number on the back of her plastic Medicaid card.
5.Indicate with an “X” whether the child lives with his/her mother.
6.Indicate with an “X” whether the child requires additional days in the hospital
7.The mother should sign the form here.
8.Enter the mother’s Social Security number.
9.Enter the mother’s daytime phone number, including the area code.
10.Indicate with an “X” whether the mother receives SSI.