NEED HELP WITH YOUR APPLICATION? If you have any questions, please call ALL Kids at our toll-free number 1-888-373-KIDS (5437) Monday through Friday from 7:30 am to 5:00 pm CST to speak to a Customer Service representative. Or you may call the Alabama Medicaid Agency at 1-800-362-1504. You may also leave a message at anytime or email us at [email protected]. Application for Health Coverage & Help Paying Costs APPLY ON-LINE at InsureAlabama.org THINGS TO KNOW Use this application to see what coverage choices you qualify for • Affordable private health insurance plans that offer comprehensive coverage to help you stay well • A new tax credit that can immediately help pay your premiums for health coverage • Free or low-cost insurance from Alabama Medicaid or ALL Kids. You may qualify for a free or low-cost program even if you earn as much as $94,000 a year (for a family of 4). Who can use this application? • Use this application to apply for anyone in your family. • Apply even if you or your child already has health coverage. You could be eligible for lower-cost or free coverage. • If you’re single, you may be able to use a short form. If you do not need help with cost, go to HealthCare.gov. • Families that include immigrants can apply. You can apply for your child even if you aren’t eligible for coverage. Applying won’t affect your immigration status or chances of becoming a permanent resident or citizen. • If someone is helping you fill out this application, you may need to complete Appendix C. What you may need to apply • Social Security Numbers (or document numbers for any legal immigrants who need insurance) • Employer and income information for everyone in your family (for example, from paystubs, W-2 forms, or wage and tax statements) • Policy numbers for any current health insurance • Information about any job-related health insurance available to your family Why do we ask for this information? We ask about income and other information to let you know what coverage you qualify for and if you can get any help paying for it. We’ll keep all the information you provide private and secure, as required by law. To view the Privacy Act Statement, go to HealthCare.gov/placeholder. What happens next? Send your complete, signed application to the address on page 11. If you don’t have all the information we ask for, sign and submit your application anyway. We’ll follow-up with you. You’ll get instructions on the next steps to complete your health coverage. If you don’t hear from us, call the Alabama Medicaid Agency at 1-800-362-1504 or call ALL Kids at 1-888-373-KIDS (5437). Filling out this application doesn’t mean you have to buy health coverage.
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APPLY ON-LINE at InsureAlabama€¦ · 2. Mailing address 3. Apartment or suite number 4. City 5. State 6. ZIP code 7. County 8. Home address (if different from mailing address) 9.
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Transcript
NEED HELP WITH YOUR APPLICATION? If you have any questions, please call ALL Kids at our toll-free number 1-888-373-KIDS (5437) Monday through Friday from 7:30 am to 5:00 pm CST to speak to a Customer Service representative. Or you may call the Alabama Medicaid Agency at 1-800-362-1504. You may also leave a message at anytime or email us at [email protected].
Application for Health Coverage & Help Paying Costs
APPLY ON-LINE atInsureAlabama.org
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Use this application to see what coverage choices you qualify for
• Freeorlow-costinsurancefromAlabamaMedicaidorALLKids.You may qualify for a free or low-cost program even if you earn as much as $94,000 a year (for a family of 4).
Weaskaboutincomeandotherinformationtoletyouknowwhatcoverageyouqualifyforandifyoucangetanyhelppayingforit.We’ll keep all the information you provide private and secure, as required by law. ToviewthePrivacyActStatement,gotoHealthCare.gov/placeholder.
What happens next?
Sendyourcomplete,signedapplicationtotheaddressonpage11. If you don’t have all the information we ask for, sign and submit your application anyway.We’llfollow-upwithyou.You’llgetinstructionsonthenextstepstocompleteyourhealthcoverage.Ifyoudon’thearfromus, calltheAlabamaMedicaidAgencyat1-800-362-1504 orcallALLKidsat 1-888-373-KIDS (5437).Fillingoutthisapplicationdoesn’tmeanyouhavetobuyhealthcoverage.
Page 1 of 11
NEED HELP WITH YOUR APPLICATION? If you have any questions, please call ALL Kids at our toll-free number 1-888-373-KIDS (5437) Monday through Friday from 7:30 am to 5:00 pm CST to speak to a Customer Service representative. Or you may call the Alabama Medicaid Agency at 1-800-362-1504. You may also leave a message at anytime or email us at [email protected].
18.MaritalStatus:(Married,Divorced,Separated,Single,Widowed) CIRCLE ONE
STEP 2Who do you need to include on this application?Tellusaboutallthefamilymemberswholivewithyou.Ifyoufiletaxes,weneedtoknowabouteveryoneonyourtaxreturn.(Youdon’tneedtofiletaxestogethealthcoverage).
DO Include:• Yourself• Yourspouse• Yourchildrenunder21wholivewithyou• Yourunmarriedpartnerwhoneedshealthcoverage• Anyoneyouincludeonyourtaxreturn,eveniftheydon’t
You DON’T have to include: • Yourunmarriedpartnerwhodoesn’tneedhealthcoverage• Yourunmarriedpartner’schildren• Yourparentswholivewithyou,butfiletheirowntaxreturn
Complete Step 2 for each person in your family. Startwithyourself,thenaddotheradultsandchildren.If you have more people in your family, you’ll need to make a copy of the pages and attach them.Youdon’tneedtoprovideimmigrationstatusoraSocialSecurityNumber(SSN)forfamilymemberswhodon’tneedhealthcoverage.We’llkeepalltheinformationyouprovideprivateandsecureasrequiredbylaw.We’llusepersonalinformationonlytocheckifyou’reeligibleforhealthcoverage.
Tell us about yourself.
Tell us about your family.
Page 2 of 11
NEED HELP WITH YOUR APPLICATION? If you have any questions, please call ALL Kids at our toll-free number 1-888-373-KIDS (5437) Monday through Friday from 7:30 am to 5:00 pm CST to speak to a Customer Service representative. Or you may call the Alabama Medicaid Agency at 1-800-362-1504. You may also leave a message at anytime or email us at [email protected].
STEP 2: PERSON 1CompleteStep2foryourself,yourspouse/partnerandchildrenwholivewithyouand/oranyoneonyoursamefederalincometaxreturnifyoufileone.Seepage1formoreinformationaboutwhotoinclude.Ifyoudon’tfileataxreturn,remembertostilladdfamilymemberswholivewithyou.
5.SocialSecurityNumber(SSN) - - We need this if you want health coverage and have an SSN. ProvidingyourSSNcanbehelpfulifyoudon’twanthealthcoveragetoosinceitcanspeeduptheapplicationprocess.WeuseSSNstocheckincomeandotherinformationtoseewho’seligibleforhelpwithhealthcoveragecosts.IfsomeonewantshelpgettinganSSN,call1-800-772-1213orvisitsocialsecurity.gov. TTYusersshouldcall1-800-325-0778.
6.Do you plan to file a federal income tax return NEXT YEAR?(Youcanstillapplyforhealthinsuranceevenifyoudon’tfileafederalincometaxreturn.)
YES. If yes,pleaseanswerquestionsa–c. NO. If no, skiptoquestionc.
a. Willyoufilejointlywithaspouse? Yes No
If yes,nameofspouse:
b. Willyouclaimanydependentsonyourtaxreturn? Yes No
If yes,listname(s)ofdependents:
c. Willyoubeclaimedasadependentonsomeone’staxreturn? Yes No
If yes,pleaselistthenameofthetaxfiler:
Howareyourelatedtothetaxfiler?
7. Areyoupregnant? Yes Noa.If Yes,howmanybabiesareexpectedduringthispregnancy? Due Date: _________
FemalesAges19-55MaybeeligibleforFamilyPlanning(BirthControl)Services.(NOTE:Youwillnotbeeligibleforthisprogramifyouhavehadyourtubestied,beensterilized,orareonMedicare)Do you want to apply for or continue to receive Family Planning? Yes No
8.Do you need health coverage? (Evenifyouhaveinsurance,theremightbeaprogramwithbettercoverageorlowercosts).
YES. If yes,answerallthequestionsbelow. NO. If no, skiptotheincomequestionsonpage3. Leavetherestofthispageblank.
9. Doyouhaveaphysical,mental,oremotionalhealthconditionthatcauseslimitationsinactivities(likebathing,dressing,dailychores,etc)orliveinamedicalfacilityornursinghome? Yes No
10. AreyouaU.S.citizenorU.S.national? Yes NoIf No, Answer #1111. If you aren’t a U.S. citizen or U.S. national,doyouhaveeligibleimmigrationstatus?
Yes.FillinyourdocumenttypeandIDnumberbelow.
a.Immigrationdocumenttype b.DocumentIDnumberc.HaveyoulivedintheU.S.since1996? Yes No d.Areyou,oryourspouseorparentaveteranoranactive-duty memberoftheU.S.military? Yes No
12.Doyouwanthelppayingformedicalbillsfromthelastthreemonths? Yes No
13.Doyoulivewithatleastonechildundertheageof19,andareyouthemainpersontakingcareofthischild? Yes No
14.Areyouafull-timestudent? Yes No 15.Wereyouinfostercareatage18orolder? Yes No
16.If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.) Mexican MexicanAmerican Chicano/a PuertoRican Cuban Other
17.Race (OPTIONAL—check all that apply.)
White BlackorAfrican American
AmericanIndianorAlaskaNative
AsianIndian Chinese
Filipino Japanese Korean
Vietnamese OtherAsian NativeHawaiian
GuamanianorChamorro Samoan OtherPacificIslander Other
(Start with yourself)
Page 3 of 11
NEED HELP WITH YOUR APPLICATION? If you have any questions, please call ALL Kids at our toll-free number 1-888-373-KIDS (5437) Monday through Friday from 7:30 am to 5:00 pm CST to speak to a Customer Service representative. Or you may call the Alabama Medicaid Agency at 1-800-362-1504. You may also leave a message at anytime or email us at [email protected].
CURRENT JOB 1:18.Employernameandaddress 19.Employerphonenumber
26.In the past year, did you: Changejobs Stopworking Startworkingfewerhours Noneofthese
27.If self-employed, answer the following questions: a.Typeofwork b. Howmuchnetincome(profitsoncebusinessexpensesare
paid)willyougetfromthisself-employmentthismonth?
$
28.OTHER INCOmE THIS mONTH: Checkallthatapply,andgivetheamountandhowoftenyougetit.NOTE: Youdon’tneedtotellusaboutchildsupport,veteran’spayment,orSupplementalSecurityIncome(SSI).
30.YEARLY INCOmE: Complete only if your income changes from month to month.If you don’t expect changes to your monthly income, skip to the next person.
Current Job & Income Information Employed Ifyou’recurrentlyemployed,tellusaboutyourincome.Startwithquestion18..
Not employed Skiptoquestion28.
Self-employed Skiptoquestion27.
Page 4 of 11
NEED HELP WITH YOUR APPLICATION? If you have any questions, please call ALL Kids at our toll-free number 1-888-373-KIDS (5437) Monday through Friday from 7:30 am to 5:00 pm CST to speak to a Customer Service representative. Or you may call the Alabama Medicaid Agency at 1-800-362-1504. You may also leave a message at anytime or email us at [email protected].
STEP 2: PERSON 2CompleteStep2foryourself,yourspouse/partner,andchildrenwholivewithyouand/oranyoneonyoursamefederalincometaxreturnifyoufileone.Seepage1formoreinformationaboutwhotoinclude.Ifyoudon’tfileataxreturn,remembertostilladdfamilymemberswholivewithyou.
5.SocialSecuritynumber(SSN) - - We need this if you want health coverage and have an SSN.
6.DoesPERSON2liveatthesameaddressasyou? Yes No
If no,listaddress:7.Does PERSON 2 plan to file a federal income tax return NEXT YEAR?(Youcanstillapplyforhealthinsuranceevenifyoudon’tfileafederalincometaxreturn.)
YES. If yes,pleaseanswerquestionsa–c. NO. If no, skiptoquestionc.a. WillPERSON2filejointlywithaspouse? Yes No
If yes,nameofspouse:
b. WillPERSON2claimanydependentsonhisorhertaxreturn? Yes No If yes,listname(s)ofdependents:
c. WillPERSON2beclaimedasadependentonsomeone’staxreturn? Yes No If yes,pleaselistthenameofthetaxfiler: HowisPERSON2relatedtothetaxfiler?
8. IsPERSON2pregnant?YesNo(circleone)a.If yes,howmanybabiesareexpected? DueDate:FemalesAges19-55MaybeeligibleforFamilyPlanning(BirthControl)Services.(NOTE:Youwillnotbeeligibleforthisprogramifyouhavehadyourtubestied,beensterilized,orareonMedicare)Do you want to apply for or continue to receive Family Planning? Yes NoIfyouareinterestedinapplyingforWIC(forpregnantorbreast-feedingwomenandchildrenunderagefive)youcanapplyatyourlocalCountyHealthDepartment.
9.Does PERSON 2 need health coverage?(Eveniftheyhaveinsurance,theremightbeaprogramwithbettercoverageorlowercosts.)
YES. If yes,answerallthequestionsbelow.
NO. If no, skiptotheincomequestionsonpage5. Leavetherestofthispageblank.
10. DoesPERSON2haveaphysical,mental,oremotionalhealthconditionthatcauseslimitationsinactivities(likebathing,dressing,dailychores,etc)orliveinamedicalfacilityornursinghome? Yes No
11. IsPERSON2aU.S.citizenorU.S.national? Yes NoIf No, Answer #1212. If PERSON 2 isn’t a U.S. citizen or U.S. national,dotheyhaveeligibleimmigrationstatus?
Yes.FillintheirdocumenttypeandIDnumberbelow.a.Documenttype b.DocumentIDnumberc.HasPERSON2livedintheU.S.since1996? Yes No d.IsPERSON2,ortheirspouseorparentaveteranoranactive- dutymemberintheU.S.military? Yes No
Please answer the following questions if PERSON 2 is 22 or younger:
16. DidPERSON2haveinsurancethroughajobandloseitwithinthepast3months? Yes No a.If yes,enddate: b.Reasontheinsuranceended:
17.IsPERSON2afull-timestudent? Yes No18.If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.) Mexican MexicanAmerican Chicano/a PuertoRican Cuban Other
19.Race (OPTIONAL—check all that apply.)
White BlackorAfrican American
AmericanIndianorAlaskaNative
AsianIndian Chinese
Filipino Japanese Korean
Vietnamese OtherAsian NativeHawaiian
GuamanianorChamorro Samoan OtherPacificIslander Other
Now, tell us about any income from PERSON 2 on the back.
Page 5 of 11
NEED HELP WITH YOUR APPLICATION? If you have any questions, please call ALL Kids at our toll-free number 1-888-373-KIDS (5437) Monday through Friday from 7:30 am to 5:00 pm CST to speak to a Customer Service representative. Or you may call the Alabama Medicaid Agency at 1-800-362-1504. You may also leave a message at anytime or email us at [email protected].
STEP 2: PERSON 2
CURRENT JOB 1:20.Employernameandaddress 21.Employerphonenumber
28.In the past year, did PERSON 2: Changejobs Stopworking Startworkingfewerhours Noneofthese
29.If self-employed, answer the following questions: a.Typeofwork b. Howmuchnetincome(profitsoncebusinessexpensesare
paid)willyougetfromthisself-employmentthismonth?
$
30.OTHER INCOmE THIS mONTH: Checkallthatapply,andgivetheamountandhowoftenyougetit.NOTE: Youdon’tneedtotellusaboutchildsupport,veteran’spayment,orSupplementalSecurityIncome(SSI).
PERSON2’stotalincomenext year (ifyouthinkitwillbedifferent)$
THANKS! This is all we need to know about PERSON 2. If you have more people to include, make a copy of Step 2: Person 2 (pages 4 and 5) and complete.
Current Job & Income Information Employed Ifyou’recurrentlyemployed,tellusaboutyourincome.Startwithquestion20..
Not employed Skiptoquestion30.
Self-employed Skiptoquestion29.
Continue with person 2
Page 6 of 11
NEED HELP WITH YOUR APPLICATION? If you have any questions, please call ALL Kids at our toll-free number 1-888-373-KIDS (5437) Monday through Friday from 7:30 am to 5:00 pm CST to speak to a Customer Service representative. Or you may call the Alabama Medicaid Agency at 1-800-362-1504. You may also leave a message at anytime or email us at [email protected].
STEP 2: PERSON 3CompleteStep2foryourself,yourspouse/partner,andchildrenwholivewithyouand/oranyoneonyoursamefederalincometaxreturnifyoufileone.Seepage1formoreinformationaboutwhotoinclude.Ifyoudon’tfileataxreturn,remembertostilladdfamilymemberswholivewithyou.
5.SocialSecuritynumber(SSN) - - We need this if you want health coverage and have an SSN.
6.DoesPERSON3liveatthesameaddressasyou? Yes No
If no,listaddress:7.Does PERSON 3 plan to file a federal income tax return NEXT YEAR?(Youcanstillapplyforhealthinsuranceevenifyoudon’tfileafederalincometaxreturn.)
YES. If yes,pleaseanswerquestionsa–c. NO. If no, skiptoquestionc.a. WillPERSON3filejointlywithaspouse? Yes No
If yes,nameofspouse:
b. WillPERSON3claimanydependentsonhisorhertaxreturn? Yes No If yes,listname(s)ofdependents:
c. WillPERSON3beclaimedasadependentonsomeone’staxreturn? Yes No If yes,pleaselistthenameofthetaxfiler: HowisPERSON3relatedtothetaxfiler?
8. IsPERSON3pregnant?YesNo(circleone)a.If yes,howmanybabiesareexpected? DueDate:FemalesAges19-55MaybeeligibleforFamilyPlanning(BirthControl)Services.(NOTE:Youwillnotbeeligibleforthisprogramifyouhavehadyourtubestied,beensterilized,orareonMedicare)Do you want to apply for or continue to receive Family Planning? Yes NoIfyouareinterestedinapplyingforWIC(forpregnantorbreast-feedingwomenandchildrenunderagefive)youcanapplyatyourlocalCountyHealthDepartment.
9.Does PERSON 3 need health coverage?(Eveniftheyhaveinsurance,theremightbeaprogramwithbettercoverageorlowercosts.)
YES. If yes,answerallthequestionsbelow.
NO. If no, skiptotheincomequestionsonpage5. Leavetherestofthispageblank.
10. DoesPERSON3haveaphysical,mental,oremotionalhealthconditionthatcauseslimitationsinactivities(likebathing,dressing,dailychores,etc)orliveinamedicalfacilityornursinghome? Yes No
11. IsPERSON3aU.S.citizenorU.S.national? Yes NoIf No, Answer #1212. If PERSON 3 isn’t a U.S. citizen or U.S. national,dotheyhaveeligibleimmigrationstatus?
Yes.FillintheirdocumenttypeandIDnumberbelow.a.Documenttype b.DocumentIDnumberc.HasPERSON2livedintheU.S.since1996? Yes No d.IsPERSON3,ortheirspouseorparentaveteranoranactive- dutymemberintheU.S.military? Yes No
Please answer the following questions if PERSON 3 is 22 or younger:
16. DidPERSON3haveinsurancethroughajobandloseitwithinthepast3months? Yes No a.If yes,enddate: b.Reasontheinsuranceended:
17.IsPERSON3afull-timestudent? Yes No18.If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.) Mexican MexicanAmerican Chicano/a PuertoRican Cuban Other
19.Race (OPTIONAL—check all that apply.)
White BlackorAfrican American
AmericanIndianorAlaskaNative
AsianIndian Chinese
Filipino Japanese Korean
Vietnamese OtherAsian NativeHawaiian
GuamanianorChamorro Samoan OtherPacificIslander Other
Now, tell us about any income from PERSON 3 on the back.
Page 7 of 11
NEED HELP WITH YOUR APPLICATION? If you have any questions, please call ALL Kids at our toll-free number 1-888-373-KIDS (5437) Monday through Friday from 7:30 am to 5:00 pm CST to speak to a Customer Service representative. Or you may call the Alabama Medicaid Agency at 1-800-362-1504. You may also leave a message at anytime or email us at [email protected].
STEP 2: PERSON 3
CURRENT JOB 1:20.Employernameandaddress 21.Employerphonenumber
28.In the past year, did PERSON 3: Changejobs Stopworking Startworkingfewerhours Noneofthese
29.If self-employed, answer the following questions: a.Typeofwork b. Howmuchnetincome(profitsoncebusinessexpensesare
paid)willyougetfromthisself-employmentthismonth?
$
30.OTHER INCOmE THIS mONTH: Checkallthatapply,andgivetheamountandhowoftenyougetit.NOTE: Youdon’tneedtotellusaboutchildsupport,veteran’spayment,orSupplementalSecurityIncome(SSI).
PERSON3’stotalincomenext year (ifyouthinkitwillbedifferent)$
THANKS! This is all we need to know about PERSON 3. If you have more people to include, make a copy of Step 2: Person 2 (pages 4 and 5) and complete.
Current Job & Income Information Employed IfPerson3iscurrentlyemployed,tellusaboutyourincome.Startwithquestion20..
Not employed Skiptoquestion30.
Self-employed Skiptoquestion29.
Continue with person 3
Page 8 of 11
NEED HELP WITH YOUR APPLICATION? If you have any questions, please call ALL Kids at our toll-free number 1-888-373-KIDS (5437) Monday through Friday from 7:30 am to 5:00 pm CST to speak to a Customer Service representative. Or you may call the Alabama Medicaid Agency at 1-800-362-1504. You may also leave a message at anytime or email us at [email protected].
STEP 2: PERSON 4CompleteStep2foryourself,yourspouse/partner,andchildrenwholivewithyouand/oranyoneonyoursamefederalincometaxreturnifyoufileone.Seepage1formoreinformationaboutwhotoinclude.Ifyoudon’tfileataxreturn,remembertostilladdfamilymemberswholivewithyou.
5.SocialSecuritynumber(SSN) - - We need this if you want health coverage and have an SSN.
6.DoesPERSON4liveatthesameaddressasyou? Yes No
If no,listaddress:7.Does PERSON 4 plan to file a federal income tax return NEXT YEAR?(Youcanstillapplyforhealthinsuranceevenifyoudon’tfileafederalincometaxreturn.)
YES. If yes,pleaseanswerquestionsa–c. NO. If no, skiptoquestionc.a. WillPERSON4filejointlywithaspouse? Yes No
If yes,nameofspouse:
b. WillPERSON4claimanydependentsonhisorhertaxreturn? Yes No If yes,listname(s)ofdependents:
c. WillPERSON4beclaimedasadependentonsomeone’staxreturn? Yes No If yes,pleaselistthenameofthetaxfiler: HowisPERSON3relatedtothetaxfiler?
8. IsPERSON4pregnant?YesNo(circleone)a.If yes,howmanybabiesareexpected? DueDate:FemalesAges19-55MaybeeligibleforFamilyPlanning(BirthControl)Services.(NOTE:Youwillnotbeeligibleforthisprogramifyouhavehadyourtubestied,beensterilized,orareonMedicare)Do you want to apply for or continue to receive Family Planning? Yes NoIfyouareinterestedinapplyingforWIC(forpregnantorbreast-feedingwomenandchildrenunderagefive)youcanapplyatyourlocalCountyHealthDepartment.
9.Does PERSON 4 need health coverage?(Eveniftheyhaveinsurance,theremightbeaprogramwithbettercoverageorlowercosts.)
YES. If yes,answerallthequestionsbelow.
NO. If no, skiptotheincomequestionsonpage5. Leavetherestofthispageblank.
10. DoesPERSON4haveaphysical,mental,oremotionalhealthconditionthatcauseslimitationsinactivities(likebathing,dressing,dailychores,etc)orliveinamedicalfacilityornursinghome? Yes No
11. IsPERSON4aU.S.citizenorU.S.national? Yes NoIf No, Answer #1212. If PERSON 4 isn’t a U.S. citizen or U.S. national,dotheyhaveeligibleimmigrationstatus?
Yes.FillintheirdocumenttypeandIDnumberbelow.a.Documenttype b.DocumentIDnumberc.HasPERSON4livedintheU.S.since1996? Yes No d.IsPERSON4,ortheirspouseorparentaveteranoranactive- dutymemberintheU.S.military? Yes No
Please answer the following questions if PERSON 3 is 22 or younger:
16. DidPERSON4haveinsurancethroughajobandloseitwithinthepast3months? Yes No a.If yes,enddate: b.Reasontheinsuranceended:
17.IsPERSON4afull-timestudent? Yes No18.If Hispanic/Latino, ethnicity (OPTIONAL—check all that apply.) Mexican MexicanAmerican Chicano/a PuertoRican Cuban Other
19.Race (OPTIONAL—check all that apply.)
White BlackorAfrican American
AmericanIndianorAlaskaNative
AsianIndian Chinese
Filipino Japanese Korean
Vietnamese OtherAsian NativeHawaiian
GuamanianorChamorro Samoan OtherPacificIslander Other
Now, tell us about any income from PERSON 4 on the back.
Page 9 of 11
NEED HELP WITH YOUR APPLICATION? If you have any questions, please call ALL Kids at our toll-free number 1-888-373-KIDS (5437) Monday through Friday from 7:30 am to 5:00 pm CST to speak to a Customer Service representative. Or you may call the Alabama Medicaid Agency at 1-800-362-1504. You may also leave a message at anytime or email us at [email protected].
STEP 2: PERSON 4
CURRENT JOB 1:20.Employernameandaddress 21.Employerphonenumber
28.In the past year, did PERSON 4: Changejobs Stopworking Startworkingfewerhours Noneofthese
29.If self-employed, answer the following questions: a.Typeofwork b. Howmuchnetincome(profitsoncebusinessexpensesare
paid)willyougetfromthisself-employmentthismonth?
$
30.OTHER INCOmE THIS mONTH: Checkallthatapply,andgivetheamountandhowoftenyougetit.NOTE: Youdon’tneedtotellusaboutchildsupport,veteran’spayment,orSupplementalSecurityIncome(SSI).
PERSON4’stotalincomenext year (ifyouthinkitwillbedifferent)$
THANKS! This is all we need to know about PERSON 4. If you have more people to include, make a copy of Step 2: Person 2 (pages 4 and 5) and complete.
Current Job & Income Information Employed IfPerson4iscurrentlyemployed,tellusaboutyourincome.Startwithquestion20..
Not employed Skiptoquestion30.
Self-employed Skiptoquestion29.
Continue with person 4
Page 10 of 11
NEED HELP WITH YOUR APPLICATION? If you have any questions, please call ALL Kids at our toll-free number 1-888-373-KIDS (5437) Monday through Friday from 7:30 am to 5:00 pm CST to speak to a Customer Service representative. Or you may call the Alabama Medicaid Agency at 1-800-362-1504. You may also leave a message at anytime or email us at [email protected].
1. Are you or is anyone in your family American Indian or Alaska Native?
2. Is anyone listed on this application offered health coverage from a job? Checkyesevenifthecoverageisfromsomeoneelse’sjob,suchasaparentorspouse.
YES. If yes,you’llneedtocompleteandincludeAppendixA.Isthisastateemployeebenefitplan? Yes No NO. If no, continue to Step 5.
STEP 4 Your Family’s Health Coverage
American Indian or Alaska Native (AI/AN) family member(s)
PRA Disclosure Statement AccordingtothePaperworkReductionActof1995,nopersonsarerequiredtorespondtoacollectionofinformationunlessitdisplaysavalidOMBcontrolnumber.ThevalidOMBcontrolnumberforthisinformationcollectionis0938-1191.Thetimerequiredtocompletethisinformationcollectionisestimatedtoaverage[InsertTime(hoursorminutes)]perresponse,includingthetimetoreviewinstructions,searchexistingdataresources,gatherthedataneeded,andcompleteandreviewtheinformationcollection.Ifyouhavecommentsconcerningtheaccuracyofthetimeestimate(s)orsuggestionsforimprovingthisform,pleasewriteto:CMS,7500SecurityBoulevard,Attn:PRAReportsClearanceOfficer,MailStopC4-26-05,Baltimore,Maryland21244-1850.
Page 11 of 11
NEED HELP WITH YOUR APPLICATION? If you have any questions, please call ALL Kids at our toll-free number 1-888-373-KIDS (5437) Monday through Friday from 7:30 am to 5:00 pm CST to speak to a Customer Service representative. Or you may call the Alabama Medicaid Agency at 1-800-362-1504. You may also leave a message at anytime or email us at [email protected].
STEP 5 Read & sign this application.
Mailyoursignedapplicationto:
ALL Kids Program P.O. Box 304839 montgomery, AL 36130-4839 1-888-373-KIDS (5437) 334-206-3783 (Fax Number)
If anyone on this application is eligible for medicaid• IamgivingtotheMedicaidagencyourrightstopursueandgetanymoneyfromotherhealthinsurance,legalsettlements,or
my right to appealIfIthinktheHealthInsuranceMarketplaceorMedicaid/Children’sHealthInsuranceProgram(CHIP)hasmadeamistake,Icanappealitsdecision.ToappealmeanstotellsomeoneattheHealthInsuranceMarketplaceorMedicaid/CHIPthatIthinktheactioniswrong,andaskforafairreviewoftheaction.IknowthatIcanfindouthowtoappealbycontactingtheMarketplaceat1-800-318-2596.IknowthatIcanberepresentedintheprocessbysomeoneotherthanmyself.Myeligibilityandotherimportantinformationwillbeexplainedtome.
Renewal of coverage in future yearsTomakeiteasiertodeterminemyeligibilityforhelppayingforhealthcoverageinfutureyears,IagreetoallowtheMarketplacetouseincomedata,includinginformationfromtaxreturns.TheMarketplacewillsendmeanotice,letmemakeanychanges,andIcanoptoutatanytime.
Sign this application. ThepersonwhofilledoutStep1shouldsignthisapplication.Ifyou’reanauthorizedrepresentativeyoumaysignhere,aslongasyouhaveprovidedtheinformationrequiredinAppendixC.