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Other Adults in Household:

Nevada Check Up (NCU) Application

Children’s Health Insurance Program (CHIP)

Questions regarding this

application? Call:

1-877-KIDS NOW (543-7669)

If previously on Nevada Check Up, please enter family identification number:

Note - We will review your application for possible Medicaid eligibility. If it appears your children may be eligible for Medicaid, we will deny NCU enrollment and may refer your case to the Division of Welfare and Supportive Services (DWSS) for a Medicaid eligibility review.

1)Do you want this application to be referred to Nevada Medicaid if applicable? Yes No

2)Are you currently applying for Medicaid medical assistance for any of the individuals listed? Yes

Person or Head of the Household Applying for Child(ren): Please fill in all the information about the person

applying for the child(ren).

(1) Last Name

Male Female

First Name

Social Security Number

Date of Birth

Marital Status

Race/Ethnicity (OPTIONAL)

Married

Single

African American

Asian

Caucasian/White

Other

Hispanic

American Indian or Alaska Native

Citizenship Status - Information received on citizenship status is not reported to INS

Preferred Language

U.S. Citizen

Undocumented Alien

Lawful Permanent Resident (LPR) as of (Date):

English

Spanish

Home Address - Number, Apt/Space and Street

City and State

Zip Code

Mailing address (if different than home)

City and State

Zip Code

Home Number

Cell/Message

Work Number

How many people in

this household?

(

)

(

)

(

)

*Will this household continue to live in Nevada? Yes *Is your rent or mortgage subsidized by an agency? No

No, explain Yes, amount

List all adults in the household regardless of relationship to child(ren) for which you are applying. If more adults reside in the household, please attach an additional sheet with the same information in the same order as listed below:

(1) Last Name

Male

Female

First Name

Social Security Number

Date of Birth

Marital Status

Race/Ethnicity (OPTIONAL)

Married

Single

African American

Asian

Caucasian/White

Other

Hispanic

American Indian or Alaska Native

Citizenship Status- Information on citizenship is not reported to INS

U.S. Citizen Undocumented Alien Lawful Permanent Resident (LPR) as of (Date):

Relationship to applicant above Spouse Sibling Child Parent Other Relative Other :

(2) Last Name

Male

Female

First Name

Social Security Number

Date of Birth

Marital Status

Race/Ethnicity (OPTIONAL)

Married

Single

African American

Asian

Caucasian/White

Other

Hispanic

American Indian or Alaska Native

Citizenship Status- Information on citizenship is not reported to INS

U.S. Citizen	Undocumented Alien	Lawful Permanent Resident (LPR) as of
		(Date):

Relationship to applicant above

Spouse Sibling Child Parent Other Relative Other :

Page 1 of 6

NCU-0100 (06/10)

Children in Household:

List all children even if they are not U.S. citizens. If more than four children reside in the household, please attach an additional sheet with the same information in the same order as listed below. If Birth Certificates are available, please provide a copy.

(1) Last Name

Male

Female

First Name

Social Security # (REQUIRED)

Date of Birth

Marital Status

Race/Ethnicity (OPTIONAL)

(REQUIRED)

Single

Married

African American

Asian

Caucasian/White

Hispanic

American Indian/Alaska Native

Other:

Citizenship Status (REQUIRED)

Is this child

Are you applying for

Is this child disabled

*Information on citizenship is not reported to INS

pregnant?

NCU for this child?

and receiving SSI?

U.S. Citizen

Undocumented Alien

Yes

Lawful Permanent Resident - provide copy of card

Due date:

Health Insurance

Parental Relationship (REQUIRED)

On Nevada Medicaid

Yes, name of insurance:

Name of mother :

No Coverage

Date coverage ended:

Type of insurance:

Name of father:

Cancer

Dental/Vision

Pharmacy

Reason:

Managed Care (HMO/PPO)

Relationship of child to applicant :

Child

Other:

Major Medical

Medicare A, B, or D

Step-Child

None

Niece/Nephew

Child Care Expenses - complete if applicable

Amount Paid:

How often paid:

(2) Last Name

Male

Female

First Name

Social Security # (REQUIRED)

Date of Birth

Marital Status

Race/Ethnicity (OPTIONAL)

(REQUIRED)

Single

Married

African American

Asian

Caucasian/White

Hispanic

American Indian/Alaska Native

Other:

Citizenship Status (REQUIRED)

Is this child

Are you applying for

Is this child

disabled and

*Information on citizenship is not reported to INS

pregnant?

NCU for this child?

receiving SSI?

U.S. Citizen

Undocumented Alien

Yes

Lawful Permanent Resident - provide copy of card

Due date:

	Health Insurance
On Nevada Medicaid	Yes, Name of Insurance:
No Coverage
Date coverage ended:	Type of insurance:
	Cancer Dental/Vision		Pharmacy
Reason:	Managed Care (HMO/PPO)
	Major Medical	Medicare A, B, or D

Parental Relationship (REQUIRED)

Name of mother :

Name of father:

Relationship of child to applicant:			Child	Other:
Step-Child	None	Niece/Nephew

Child Care Expenses - complete if applicable

Amount Paid:

How often paid:

(3) Last Name

Male

Female

First Name

Social Security # (REQUIRED)

Date of Birth

Marital Status

Race/Ethnicity (OPTIONAL)

(REQUIRED)

Single

Married

African American

Asian

Caucasian/White

Hispanic

American Indian/Alaska Native

Other:

Citizenship Status (REQUIRED)

Is this child

Are you applying for

Is this child disabled

*Information on citizenship is not reported to INS

pregnant?

NCU for this child?

and receiving SSI?

U.S. Citizen

Undocumented Alien

Yes

Lawful Permanent Resident - provide copy of card

Due date:

Health Insurance

Parental Relationship (REQUIRED)

On Nevada Medicaid

Yes, Name of Insurance:

Name of mother :

No Coverage

Date coverage ended:

Type of insurance:

Name of father:

Cancer

Dental/Vision

Pharmacy

Reason:

Managed Care (HMO/PPO)

Relationship of child to applicant:

Child

Other:

Major Medical

Medicare A, B, or D

Step-Child

None

Niece/Nephew

Child Care Expenses - complete if applicable

Amount Paid:

How often paid:

Page 2 of 6

NCU-0100 (06/10)

(4) Last Name

Male

Female

First Name

Social Security # (REQUIRED)

Date of Birth

Marital Status

Race/Ethnicity (OPTIONAL)

(REQUIRED)

Single

Married

African American

Asian

Caucasian/White

Hispanic

American Indian/Alaska Native

Other:

Citizenship Status (REQUIRED)

Is this child

Are you applying for

Is this child disabled

*Information on citizenship is not reported to INS

pregnant?

NCU for this child?

and receiving SSI?

U.S. Citizen

Undocumented Alien

Yes

Lawful Permanent Resident - provide copy of card

Due date:

Health Insurance

Parental Relationship (REQUIRED)

On Nevada Medicaid

Yes, Name of Insurance:

Name of mother :

No Coverage

Date coverage ended:

Type of insurance:

Name of father:

Cancer

Dental/Vision

Pharmacy

Reason:

Managed Care (HMO/PPO)

Relationship of child to applicant:

Child

Other:

Major Medical

Medicare A, B, or D

Step-Child

None

Niece/Nephew

Child Care Expenses - complete if applicable

Amount Paid:

How often paid:

Employment Information: List employment information for each adult residing in the household. *See insert for acceptable income verification (not more than 45 days old).

(1) Person Employed - Last, First

Name of Employer

Employer Address

Employer Telephone

(

)

Gross Pay - amount before taxes

Tips per pay period

How Often Paid

Weekly

Every 2 weeks

Twice a month

Monthly

Other:

(2) Person Employed - Last, First

Name of Employer

Employer Address

Employer Telephone

(

)

Gross Pay - amount before taxes

Tips per pay period

How Often Paid

Weekly

Every 2 weeks

Twice a month

Monthly

Other:

Other Income: Please provide the most current proof (not more than 45 days old) for each income received. List all types of income received by anyone in the household (including children) and leave blank if not applicable.

Source of Other Income

Name of Recipient

Dollar

How Often Paid

Amount

Child Support/Alimony

Weekly

Every 2 weeks

Other:

Twice a month

Monthly

Social Security Payments - select

Weekly

Every 2 weeks

Other:

RSDI

SSI

Twice a month

Monthly

Disability Payment Source

Weekly

Every 2 weeks

Other:

Twice a month

Monthly

Unemployment Benefits

Weekly

Every 2 weeks

Other:

Twice a month

Monthly

Pension Payment and Source

Weekly

Every 2 weeks

Other:

Twice a month

Monthly

Interest or Dividends (Stocks, Bonds,

Weekly

Every 2 weeks

Other:

Twice a month

Monthly

Trusts, Mutual Funds, Savings, etc.)

Other (such as cash assistance, etc)

Weekly

Every 2 weeks

Other:

Twice a month

Monthly

Page 3 of 6

NCU-0100 (06/10)

Health Plan Selection: Please choose a health plan:

*Note: If you do not choose a health plan preference, we will choose a plan for you (see insert for choices).

Referral Information: How did you hear about Nevada Check Up? (Please check the ONE that applies)


Covering Kids and Families		Welfare	School	WIC	Media (Newspaper, TV and Radio)		Internet		Friend/Family
Doctor/Hospital	Social Services/Health Dept			Child Care Provider		Tribal Resource	Clinic	Other:

Signature and Affirmation:

It is your responsibility to immediately report to Nevada Check Up any of the following status changes for your children:

OChange of address and phone number

OMoves out of the house or state

OChild(ren) becomes eligible for Medicaid or other health insurance

OA household member becomes deceased

OChild(ren) becomes a resident, inmate of a public institution or a ward of the state

OChild(ren) becomes emancipated and/or married

In signing this document, I hereby apply for health insurance coverage for the named children under the Nevada Check Up program. I agree to adhere to all the required responsibilities to report changes listed on this application. I certify that all information contained is true and accurate to the best of my knowledge and that no facts have been left out.

I hereby release Nevada Check Up from liability, if any, resulting from the disclosure of information contained in this application.

I understand and authorize Nevada Check Up and/or the Department of Health and Human Services to contact any party deemed necessary to verify information presented on the application.

If any of my household members receive Nevada Check Up, I agree to assign all rights to any medical claims, medical support or other payments for medical care. I understand this is a condition of being eligible for Nevada Check Up. I agree to cooperate with the division in obtaining payments for medical care from any third party or person who may be liable for the medical services paid for by Nevada Check Up. I also understand I must inform Nevada Check Up if any legal action is taken against anyone or if I receive any offer or settlement for the reimbursement of medical care and treatment that may be paid for by Nevada Check Up.

I understand the eligibility determination process may take 45 days. The 45 days starts when a complete application with all necessary, requested and required documentation is received. Once approved, I will be notified by mail of the date coverage begins and my premium amount. If the application is denied or Nevada Check Up makes any other decision with which I don’t agree, including timeliness of the determination within established guidelines, I have the right to request a hearing. The request for hearing must be submitted in writing within 30 days of the date of the denial letter.

A reproduced copy of this authorization constitutes an original copy.

I declare under penalty of perjury under the laws of the State of Nevada that the foregoing is true and correct. (NRS 53.045, NRS 199.120 thru NRS 199.200 and NRS 41.365).

I further understand that the law provides penalties for persons hiding facts or not being completely truthful.

I understand that information provided to NCU may be verified or investigated by federal, state and local officials. If I do not cooperate in the investigation, my child(ren)’s benefits will be denied or terminated. If I make false or misleading statements;

misrepresent, conceal or withhold facts; or alter any document necessary to make an accurate eligibility determination, my child(ren)’s benefits may be denied or terminated. I am responsible for repayment of all monies paid for services to which my

child(ren) were not entitled and I may be subject to any criminal and/or civil penalties in accordance with state and federal law.

Applicant Signature:		Date:

(Mandatory) If not signed, application will be rejected.

Other Adult:		Date:

Send your completed application or any correspondence to: Nevada Check Up Program 1000 E. William Street Ste 200 Carson City, Nevada 89701

Questions? Call us at (775) 684-3777 or toll free 1-877-KIDS-NOW (543-7669). Our fax number is (775) 684-8792. Spanish speaking staff is always available! You may also visit us on our website: http://nevadacheckup.nv.gov

If you believe someone has interfered with your right to register to vote, your right to choose your own political party or other political preference, you may file a complaint with the Office of the Secretary of State, Capitol Complex, Carson City, Nevada 89710.

The Department of Health and Human Services, Division of Health Care Financing and Policy, provides services without discrimination of any kind due to race, national origin, color, gender, religion, age or disability (including AIDS and related conditions) as required by federal law.

Page 4 of 6

NCU-0100 (06/10)

1-877-KIDS-NOW (543-7669)	Nevada Check Up
Fax (775) 684-8792	1000 E Williams Street, Suite 200
	Carson City, NV 89701

What is Nevada Check Up?

The state of Nevada Children’s Health Insurance Program (CHIP) known as “Nevada Check Up” is a federal and state funded program that provides low-cost health care coverage to uninsured children from birth through 18 years of age who meet the program guidelines.

What health services are covered?

Most medically necessary services are covered. Nevada Check Up offers comprehensive medical, dental and medical vision care for children.

What are the eligibility qualifications for Nevada Check Up?

2011

Number of	200% FPL
People in	Max Income
Household	Level
2	$29,420

3	$37,060

4	$44,700

5	$52,340

6	$59,980

Children must meet the following conditions:

Not be covered by or appear eligible for Medicaid

Have no other health care coverage or had insurance in the last six months

Not be covered by or have access to the Public Employee Benefits Program (PEBP)

Be a citizen of the United States or a Lawful Permanent Resident (LPR) for five years

O Please note that applying for Nevada Check Up will not affect your family’s immigration status

Meet federal income guidelines (be within 200% of the Federal Poverty Level)

OApplicants that currently exceed the listed 200% FPL may still qualify for our program in the future as the Federal Poverty Levels can change

Be younger than 18 years and 11 months at the time of the application

What about premium payments?

The only cost for Nevada Check Up is a quarterly premium which is determined by family size and income. The premium is charged per family, not per child. Below is a chart which shows the premium amount associated with the Federal Poverty Level (FPL). For American Indian families who are members of federally recognized tribes, or an Eskimo, Aleut or other Alaska Native enrolled by the Secretary of the Interior, quarterly premiums are waived when proof of status (copy of the tribal affiliation card) is provided.

Premium	FPL

$25	From 36% up to 150%

$50	From 151% up to 175%

$80	At or above 176%

Families are informed of their premium amount once they are enrolled. If families are enrolled during a quarter premiums will be prorated. If your child(ren) were previously on NCU and have an existing unpaid premium balance, children will not be enrolled until payment is received. Payment arrangements can be made which would not exceed 60 days.

Note - Failure to pay premiums will result in disenrollment

Quarters	Due Date

1st Quarter	October 1st
Oct, Nov, Dec

2nd Quarter	January 1			st
Jan, Feb, Mar	January 1
Jan, Feb, Mar

3rd Quarter	April 1		st
Apr, May, Jun	April 1
Apr, May, Jun

4th Quarter	July 1	st
Jul, Aug, Sept	July 1
Jul, Aug, Sept

Page 5 of 6

PLEASE KEEP FOR YOUR RECORDS

NCU App Insert English (06/10)

1-877-KIDS-NOW (543-7669)	Nevada Check Up
Fax (775) 684-8792	1000 E Williams Street, Suite 200
	Carson City, NV 89701

How often must I re-qualify for Nevada Check Up?

Once a year, Nevada Check Up will send a request for updated information. Recipients will also be requested to send new income verification documents. If you do not respond by the deadline, your children will no longer be covered by Nevada Check Up. Families will only receive notification if their case will be disenrolled.

Health Plan

Families who live in urban Washoe County or urban Clark County are covered by a Managed Care Organization (MCO). You are asked to choose one of the following health plans on page four of the application under Health Plan Selection. If you do not indicate a health plan preference on your application, we will choose a plan for you. Your choice of health plan does not guarantee acceptance into the Nevada Check Up program. Once enrolled, families will receive a member handbook explaining the health plan benefits and can contact the numbers below for information regarding the health plans.

Amerigroup : 1-800-600-4441

Health Plan of Nevada : 1-800-962-8074

For families living in the Fee-For-Service benefit area, services may be obtained from any Nevada Medicaid provider who will accept Nevada Check Up. If you need assistance in locating a provider, please call your local Medicaid District Office:

Carson City (775) 684-3653 Reno (775) 688-2811 Las Vegas (702) 486-1550 Elko (775) 753-1191

Third Party Liability

A condition of being eligible for Nevada Check Up is the agreement to assign all rights to any medical claims, medical support or other payments for medical care. Recipients must cooperate with the division in obtaining payments for medical care from any third party or person who may be liable for the medical services paid for by the Nevada Check Up Program. Recipients must inform Nevada Check Up if any legal action is taken against anyone or if any offer or settlement is received for the reimbursement of medical care and treatment that may be paid for by the Nevada Check Up Program.

Investigations and Referrals

Information provided to NCU may be verified or investigated by federal, state and local officials. If you do not cooperate in the investigation, which may include a home visit, your benefits will be denied or terminated. If you make false or misleading statements, misrepresent, conceal or withhold facts; or alter any document necessary to make an accurate eligibility determination, your benefits may be denied or terminated. You are responsible for repayment of all monies paid for services to which you were not entitled and you may be subject to any criminal and/or civil penalties in accordance with state and federal law.

ADDITIONAL DOCUMENTATION NEEDED FOR A COMPLETE APPLICATION:

Employed

Proof of income - two current and consecutive pay stubs (not more than 45 days old from application date) *If paycheck stubs are not available you need to contact Nevada Check Up for an Earnings Verification Form

Unemployed

Current unemployment award letter if receiving unemployment benefits

Self-employed

Complete copy of last year’s tax return

Last 3 months of personal and business bank statements

Other Income

Current year award letter for RSDI, SSI, Worker’s Compensation, VA Benefits, Disability Benefits, Pension Payments, interest/dividends received, proof of money from property (rent received) and proof of any other income not listed

Proof of child support including amount and frequency per child if applicable

Page 6 of 6

PLEASE KEEP FOR YOUR RECORDS

NCU App Insert English (06/10)

Question	Answer
Form Name	Nevada Check Up Form
Form Length	6 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 30 sec
Other names	SSI, LPR, FPL, Nevada

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