Nj Pa 1G Form PDF Details

In a notable development within the healthcare sector, the State of New Jersey's Department of Human Services, specifically the Division of Medical Assistance and Health Services, has announced an important update to the Medicaid application process, pivotal for entities such as County Welfare Agency Directors and Institutional Services Section (ISS) Supervisors. This update, encapsulated in the revised Medicaid application form, PA-1G, dated August 15, 2012, represents a significant step towards accommodating the evolving landscape of Medicaid provisions. The modifications introduced in the updated form encompass a broad spectrum of areas, aiming to streamline and simplify the process for applicants. These changes include an expanded Resources section, addressing components like investments, property, and trusts, alongside a clarified depiction of Rights and Responsibilities and a refined articulation of the Income and Resources sections. This effort demonstrates New Jersey's commitment to ensuring that the application process is both inclusive and accessible, reflecting changes in the Medicaid program in recent years. Additionally, the anticipation of the form's translation into Spanish highlights a sensitivity towards linguistic inclusivity, aiming to widen the form's accessibility. This update is not just a procedural change; it signifies a broader intent to evolve with the healthcare needs and circumstances of the state's residents.

QuestionAnswer
Form NameNj Pa 1G Form
Form Length10 pages
Fillable?No
Fillable fields0
Avg. time to fill out2 min 30 sec
Other namesnj medicaid application form, medicaid application form nj, medicaid nj application forms, nj medicaid forms

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State of New

Jersey

 

 

DEPARTMENT OF HUMAN SERVICES

 

 

DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES

 

CHRIS CHRISTIE

P.O. Box 712

 

JENNIFER VELEZ

Governor

Trenton, NJ 08625-0712

Commissioner

KIM GUADAGNO

 

 

VALERIE HARR

Lt. Governor

 

 

Director

MEDICAID COMMUNICATION NO. 12-14

DATE: August 15, 2012

 

TO:

County Welfare Agency Directors

 

 

 

Institutional Services Section (ISS) Supervisors

 

SUBJECT: Updated Medicaid Application (PA-1G)

The Division has updated the Medicaid application (PA-1G) to reflect changes in the Medicaid program over the last few years. The major changes include but are not limited to:

-An expanded Resources section (Investments, Property, Trusts, etc.)

-Clarified and updated the Rights and Responsibilities

-Simplified and refined the Income and Resources sections

You may continue to use any unused copies of the previous application before utilizing the attached updated application. We are in the process of having this updated application translated into Spanish, and will distribute that once complete.

If you have any questions regarding this Medicaid Communication, please refer them to the Division’s Office of Eligibility Policy field service staff for your agency at

609-588-2556.

Sincerely,

Valerie Harr

Director

VH:m

Attachment

New Jersey Is An Equal Opportunity Employer

Page 2

c:Jennifer Velez, Commissioner Department of Human Services

Dawn Apgar, Deputy Commissioner Division of Developmental Disabilities

Lowell Arye, Deputy Commissioner Aging and Community Services

Lynn Kovich, Assistant Commissioner

Division of Mental Health and Addiction Services

Joseph Amoroso, Director Division of Disability Services

Raquel Jeffers, Deputy Director

Division of Mental Health and Addiction Services

Kathleen M. Mason, Director Division of Aging Services

Jeanette Page-Hawkins, Director Division of Family Development

Allison Blake, Commissioner Department of Children and Families

Mary E. O’Dowd, Commissioner

Department of Health

MEDICAID APPLICATION

 

CASE #

Why do you need help at this time?

If disabled, what date did you become disabled?

What is the nature of your disability?

Do you need special assistance to complete this application?

Have you filled out an application before?

Yes

No If yes, where and when?

Based on the above information, please check all program(s) / service(s) requested:

Home & Community Based Services / Waiver

New Jersey Care…Special Medicaid Program

Nursing Home / Institutional

State of New Jersey

Assisted Living

Department of Human Services

NJ WorkAbility

 

Medically Needy Program

DMAHS

Medicaid Only Program

 

Other:

 

 

This is a legal document and subject to verification. Application must be completed truthfully and accurately.

SECTION I

Basic Information

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Applicant’s Name:

 

 

 

 

 

 

 

 

 

Phone #:

 

 

 

 

 

 

 

 

 

 

Last Name

First

 

M.I.

Maiden Name

 

 

 

 

 

 

 

 

 

 

 

Applicant’s E-mail Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Birth Date:

 

 

 

 

 

Birth Place:

 

 

 

 

Social Security #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(or Railroad Retirement #)

 

 

 

Sex:

Male

Female Marital Status:

 

Single

Married

Separated

 

Divorced

 

Widowed

Child

 

 

Do you receive Supplemental Security Income Benefits?

Yes

No

Date applied for:

 

 

 

 

 

 

 

Have you been denied SSI benefits within the last 12 months?

Yes

 

No If yes, why?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Are you a United States Citizen?

Yes

No If no, explain citizenship status:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Alien #

 

 

 

 

 

 

 

Have you, your spouse, or parent (if applying for a child) served in the U.S. Armed Forces?

Yes

No

 

 

 

If yes, Name:

 

 

 

 

 

 

 

 

 

VA# (if known):

 

 

 

 

 

 

 

SECTION II

Residence

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current Residence:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street

 

 

 

 

 

City/Town

 

 

State

Zip

 

Mailing Address (if different):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you plan to continue living in New Jersey?

Yes

 

No If no, explain:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Previous addresses for the past five years: (if additional space is needed, use separate paper)

 

 

 

 

 

From

 

 

 

 

To

 

 

 

 

From

 

 

To

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

At:

 

 

 

 

 

 

 

 

At:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Signature of Person Initiating Application

 

 

Date

 

 

 

 

 

 

 

 

Relationship to Applicant – Parent, Spouse, Legal Guardian, etc.

 

E-mail Address

 

 

 

 

 

 

 

 

 

 

Phone #

 

Address

 

 

 

 

 

PA-1G Revised 3/12

 

 

 

 

Page 1 of 8

SECTION III Marital Status Information

 

 

 

 

 

 

 

 

 

 

Name of Spouse:

 

 

Social Security #:

 

 

 

 

 

Birth Date:

 

 

 

Date of Marriage:

 

City/State where married:

 

 

 

 

 

 

 

 

 

 

Name of former Spouse (if applicable):

 

 

 

 

 

 

 

Social Security #:

 

 

Address:

 

 

 

 

 

 

 

 

 

County:

 

 

Date of Separation (if applicable):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Divorce (if applicable):

 

 

 

Where divorced:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If Spouse is deceased, list date and city/state of death:

If applying for a child, list name of parents:

SECTION IV Living Arrangements

In order to calculate your benefit, we need information regarding your living arrangements.

If hospitalized / institutionalized, please complete this based on where you lived prior to entering the hospital or institution.

1. Do you: (Please check ALL boxes that apply.)

 

Own your own home?

 

 

 

Rent a

House?

Room?

Apartment?

 

Is your name on the lease?

Yes No

Live in a residential health care facility?

 

Live in a licensed boarding home?

Live alone, or with your spouse? (If you live with children, please list them in #2 below.)

Live with a relative or friend?

Have other living arrangements not described above? Please explain:

Purchase and prepare your own meals?

Share your meals with others?

2.

List other people living with you. Include name, age, and relationship.

 

 

 

 

 

 

 

 

 

3.

How much is your household’s rent or mortgage?

 

What portion do you pay?

 

 

 

 

 

 

 

 

 

 

 

Name and address of Mortgage Company or landlord:

 

 

 

 

SECTION V Earned and Unearned Income Information

Do you have income direct deposited to an account?

Yes

No

Employment:

List income for you, your spouse, or parent(s) (if applying for a child).

Please complete the following (including self-employment):

If not employed, check here

Person Employed

Name & Address of Employer

Gross Pay

Amounts

How Often Paid

(Weekly, Monthly, etc)

PA-1G Revised 3/12

Page 2 of 8

SECTION VI Benefits or Other Income

If you/your spouse/parent(s) with whom the applicant child lives, received, or have applied for income from any sources listed below, please complete all information that applies:

 

 

 

Applied

 

 

 

 

 

 

For/Have

If Benefit is

Name of

 

 

 

 

Potential

 

 

Gross

How Often

To

Pending:

Recipient or

Claim # or

 

Income

(Weekly/

Receive

Date of

Potential

Account # (if

Other Income

Received

Monthly)

(Yes/No)

Application

Recipient

applicable)

Social Security Benefits –

Including Retirement,

Disability or Survivor Benefits

Railroad Retirement

Supplemental Security

Income (SSI)

Pensions, including Private,

Government, Foreign

Annuities

Dividends, Royalties, Interest

Reparation Payments including German, Austrian, Other

Veterans Benefits / Military

Allotment or Pay

Unemployment Benefits /

Workers Compensation

Cash Public Assistance (TANF/GA)

Sick or Disability Payments

Payment from Boarders, Rent

Cash Support including

Child Support, Alimony

If anyone is helping to support you such as giving or loaning you money, list amount.

In Kind Support, including help with food, bills or shelter

Other Income (Non-Wages) including Strike or Black Lung Benefits

If you have no income or potential entitlement, check here

Lump Sum Income

If you received a Lump Sum Payment (including but not limited to winnings, gifts, inheritance, retroactive wages or benefits, etc.), indicate source, gross amount, and date received:

PA-1G Revised 3/12

Page 3 of 8

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Tips to fill out nj medicaid application online stage 1

2. After filling in this section, head on to the subsequent stage and fill out all required particulars in all these fields - Male, Female Marital Status, This is a legal document and, If no explain citizenship status, CityTown, No Date applied for, Zip, State, VA if known, If yes why, Widowed, Child, Alien, Single, and Married.

State, This is a legal document and, and Zip in nj medicaid application online

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nj medicaid application online writing process described (portion 3)

People who work with this PDF often make errors while filling in Email Address in this area. Ensure you go over everything you enter here.

4. Completing SECTION III Marital Status, Name of Spouse, Date of Marriage, Social Security, Birth Date, CityState where married, Name of former Spouse if applicable, Address, Date of Separation if applicable, Social Security, County, Date of Divorce if applicable, Where divorced, If Spouse is deceased list date, and If applying for a child list name is key in the fourth stage - always take the time and take a close look at each and every empty field!

Stage # 4 of filling out nj medicaid application online

5. The document should be wrapped up within this part. Below there can be found a comprehensive list of fields that need specific details for your form submission to be accomplished: Is your name on the lease Live in, Yes, Live in a licensed boarding home, Live with a relative or friend, Share your meals with others, List other people living with you, Name and address of Mortgage, What portion do you pay, SECTION V, Earned and Unearned Income, Do you have income direct, and Yes.

Completing part 5 in nj medicaid application online

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