Completing forms and applications can often be an intricate task, particularly when it involves applying for health coverage. The Indiana Application for Health Coverage, documented as State Form 55390 (9-13), serves as a cornerstone for residents seeking medical insurance within the state. Applicants are prompted to provide detailed personal information, including ethnicity, citizenship or immigration status, and employment details. The form also caters to a variety of circumstances by asking about living arrangements, dependent information, and specific situations such as pregnancy, disability, and whether the person is currently residing in a facility like a nursing home or is incarcerated. Furthermore, it requires disclosure of income sources not just from employment but also other areas like unemployment benefits, Social Security, and even tribal income for American Indian or Alaska Native applicants. This comprehensive approach ensures the state can accurately assess eligibility for health coverage or specific services like Family Planning, based on a wide array of factors. Importantly, the form is designed to be inclusive, asking for relevant details about family members and dependents where applicable. By signing the application, the individual attests to the truthfulness of the provided information under penalty of perjury, emphasizing the seriousness and significance of the application process. State Form 55390 not only serves as an initial step towards obtaining health coverage but also as a means to ensure that all residents have the opportunity to apply for the assistance they may be eligible for.
| Question | Answer |
|---|---|
| Form Name | State Form 55390 |
| Form Length | 18 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 4 min 30 sec |
| Other names | where to fax indiana form 55390, state form 55390 r7 8 17, in application for health coverage form 55390, indiana state form 55390 |
Indiana Application for Health Coverage
State Form 55390
*DFRAMAE01*
INSTRUCTIONS: Please fill out your application as completely as you can. It will help if you can answer all of the questions. Please do not forget to sign your application on Page 1 Section 5.
1.If you are completing this application on behalf of someone else and you do not live in their household, please provide your name below and contact information in section 32. If you are completing this application on behalf of someone
else and you do live in their household, please provide your information in Section 20:
First Name |
MI Last Name |
Suffix |
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2.Information for person needing assistance: (additional individuals may be added in Section 20)
Check the Help This Person Needs:
Health Coverage
Not Applying
If Health Coverage is checked and you are not eligible for full benefits, do you want to be considered for Family Planning Services only? Yes
If Not Applying is checked, completion of the Social Security Number is optional.
First Name |
MI Last Name |
Suffix |
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No
Date of Birth |
Social Security Number |
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Marital Status: |
Single |
Married |
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Divorced |
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3. Home Address: |
Number and Street |
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Gender: |
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M |
F |
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Separated |
Widowed |
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Apartment/Lot Number
City
State
Zip Code
County:
Telephone Number:
How many people live at this address including you?
OFFICIAL USE ONLY
4.Mailing Address (if different than home address):
City |
State |
Zip Code |
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5. Signature Required
I certify under penalty of perjury, all information I have given on this application, any attachments and information provided during the eligibility determination process is complete and correct to the best of my knowledge and belief, including the citizenship or immigration status of each applicant.
Signature |
Date |
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Signature of witness if signed with “X”
Go to the next page
DFRAMAE01
Indiana Application for Health Coverage
State Form 55390
6. Ethnicity/Race
Ethnicity: |
Are you Hispanic or Latino? |
Yes |
No |
*DFRAMAE02*
Race: (select all that apply)
White |
Black or African American |
Asian |
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American Indian or Alaskan Native |
Native Hawaiian or Pacific Islander |
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If American Indian or Alaska Native, please answer the questions below:
Are you a member of a federally recognized tribe? |
Yes |
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No |
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If yes, enter tribe name |
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Have you received a service from the Indian Health Service, a tribal health program, or urban Indian health program, |
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Yes |
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No |
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or through a referral from one of these programs? |
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If no, are you eligible to get services from the Indian Health Service, tribal health programs, or urban Indian health |
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Yes |
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No |
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programs, or through a referral from one of these programs? |
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7. Citizenship/Immigration Information
Are you a U.S. citizen or U.S. national?
If no , select your immigration status:
Yes
No
Lawful Permanent Resident
Refugee
Granted Political Asylum
Cuban/Haitian Entrant
Parolee
Amerasian
Undocumented
Other
Date of Status:
Date of entry into the U.S.
Country of origin
Document
Number
Document Type
First Name |
MI Last Name |
Name as it appears on the document:
Date of birth as it appears on the
Are you, or your spouse or parent a veteran or an
Yes
No
8. Additional Information For Person Needing Assistance
Do you live with at least one child under the age of 18, and are you the main person taking care of this child?
Are you Pregnant? |
Yes |
No |
If yes, how many babies are expected during this pregnancy? |
Yes
No
Pregnancy begin date |
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Pregnancy due date |
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Are you blind? |
Yes |
No |
Are you disabled? |
Yes |
No |
Are you incarcerated? |
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Are you living in a nursing facility? |
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Yes |
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No |
Are you pending for or receiving a Medicaid Waiver? |
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Are you living in a Residential Care Facility or Room and Board Facility? |
Yes |
No |
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Yes
Yes
No
No
Go to the next page
DFRAMAE02