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Medicaid Application 1
Medicaid Application 1
Form 94 (11/10)
We will consider this application without regard to race,
color, sex, age, disability, religion, national origin or
political belief.
Pregnant Woman
Families w/Children – LIM
Date Received in County Dept
Check block(s) that
Child(ren) Only – RSM
Chafee Independence Program Medicaid
apply to you: Were you in foster care on your 18
birthday Yes No In which state______
PLEASE NOTE: A Face to Face interview is not required for Medicaid applications. Please answer all questions as completely and accurately as possible. If you cannot understand or complete this application,
please notify DFCS staff and assistance will be provided free of charge.
Your Name: (Please Print) FIRST M.I. Last Maiden (if applicable) Today’s Date:
Mailing Address: City: State: Zip Code:
Residence Address (if different from Mailing Address): Phone Number(s): E-mail Address:
Please list all persons living with you for whom you want Medicaid. List yourself if you want Medicaid for yourself.
First Name MI Last Name
(Jr.) Race
M/F Date of Birth Relationship to You
Social Security
Is this
Person a
(you may
qualify for
even if you
answer No)
Does the
Father of
this child
live in
Does the
Mother of
this child
live in your
Please list all persons living with you for whom you DON’T want Medicaid. List yourself if you don’t want Medicaid. You do not have to provide a SSN or immigration status information for any
person who is not asking for Medicaid. If provided, we will use the SSN for computer matches with other agencies and it may help us process your child’s application. We will NOT share your
information with the Department of Homeland Security (formerly the INS).
Is anyone in the household pregnant Yes No If yes, who is pregnant _________________________ Due Date: ____________ Please attach verification of pregnancy if available.
Do you have any unpaid medical bills from the past three months Yes No If yes, which months _________________________________________________________________
Does anyone in your household have Health Insurance Yes No If yes, list Insurance Company and policy number:
Have you or anyone in your household been diagnosed with Breast or Cervical Cancer Yes No If yes, have you received Women’s Health Medicaid previously Yes No
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Medicaid Application 1