Fillable Printable Model Medicaid Renewal Form
Fillable Printable Model Medicaid Renewal Form
Model Medicaid Renewal Form
It is time to renew your Medicaid coverage.
You can renew your
Medicaid in any
one of these ways
Renewing online is faster! Go to <web address> and click on Renew My Medicaid
By phone: Just call 1-800-XXX-XXXX (TTY: 1-888-XXX-XXXX). The call is free.
By mail: Complete this form and mail it to:
[Medicaid Agency]
[100 State Street]
[Anycity, State]
In person: Visit our office at [Medicaid Agency] [100 State Street] [Anycity, State].
Office hours are 8:30 a.m. to 5 p.m. Monday to Friday, and 9:00 a.m. to 12 p.m. on
Saturday.
How to complete
this renewal form
1.
Answer all of the questions on the form.
2.
Read the information about you and each member of your household. Add any
missing information. If any information has changed, write in the right information.
3.
Sign the form on page 9.
4.
Return this form by December 12, 2013. If you do not return the form by this
deadline, you will lose your Medicaid coverage.
What we need
We need information about each person living in your household or listed on
your tax return, including:
those who get Medicaid now,
those who do not get Medicaid now but would like to apply, and
others who live in the household and do not get Medicaid but do not want to apply.
We will check your answers using information from computer data sources,
including the Internal Revenue Service (IRS), the Social Security Administration,
the Department of Homeland Security and others. If the information does not
match, we may ask you to send more information.
If you do not qualify
for Medicaid
If you do not qualify for Medicaid, [state agency] will check to see if you qualify
for other kinds of health coverage. [State agency] may send your information to
another program so they can see if you qualify.
You can get this notification in another language
or in large print or another way that’s best for you.
Call 1-800-XXX-XXXX (TTY: 1-888-XXX-XXXX).
Medicaid
Renewal Form
Mary Smith
123 Smith Street
Smithtown, FL 00000
November 5, 2013
Respond by: December 12, 2013
Letter number: 34567
Questions? Call [state agency] at 1-800-XXX-XXXX. The call is free. (TTY: 1-888-XXX-XXXX).
You can call [days and hours of operation]. Or visit <web address>.
1
?
1
Your contact information
Review your contact information here. Correct any wrong or missing information here.
Ernie Roberts
Home address:
1234 America Ave. Apt. 1A
Anywhere, ST 12345
Mailing address:
5678 Broad St.
P.O. Box 6789
Anywhere, ST 12345
Phone:
Home: 111-222-3333
Other:
Name (first, middle, last & suffix)
Home address Apartment #
City (home) State ZIP code
Mailing address Apartment #
City (mailing) State ZIP code
Best phone number to reach you:
Home
Cell
Work
Number:
Other phone number, if you have one:
Home
Cell
Work
Number:
Email address, if you have one:
2
We need information about who files tax returns.
You can still renew if you do not file tax returns.
Will anyone in the household file a federal tax return next year to report income earned this year?
Yes If yes, answer all of the questions below.
No If no, answer the question marked with a star below
Person 1: Name (first, middle, last & suffix)
If this person is filing a joint return, write the name of the spouse:
If this person will claim dependents, write the names of the dependents:
Person 2: Name (first, middle, last & suffix)
This is for a second tax filer in the household
If this person is filing a joint return, write the name of the spouse:
If this person will claim dependents, write the names of the dependents:
If anyone will be claimed as a dependent on someone else's tax return, write the name of the tax filer
and the dependents. Answer only if different than what you reported above or if you did not fill in any
information above.
Name of tax filer: _______________________________________________________________________________________________________________________________________________________________________
Name of dependents: ___________________________________________________________________________________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________________________________________________
Questions? Call [state agency] at 1-800-XXX-XXXX. The call is free. (TTY: 1-888-XXX-XXXX).
You can call [days and hours of operation]. Or visit <web address>.
2
?
3
These are the people in your household who
get Medicaid and need to renew now
Person 1
Samantha Roberts
Check here if
this person is
no longer living
in the household.
S
The [state agency name] has this person’s Social Security number.
The [state agency name] does not have this person’s Social Security number. Write it in the spaces below.
___
–
__
–
____
If this person is an immigrant, for their immigration status:
You need to fill in the information below.
S
You do not need to fill in the information below because [state Medicaid agency] has it.
Check here if this person has eligible immigration status and fill in the document type: _____________________________________________________________________________
and ID number: ______________________________ .
See Attachment D on page 13 for more information about eligible immigration status and document types.
Person 2
Benjamin Roberts
Check here if
this person is
no longer living
in the household.
The [state agency name] has this person’s Social Security number.
S
The [state agency name] does not have this person’s Social Security number. Write it in the spaces below.
___
–
__
–
____
If this person is an immigrant, for their immigration status:
You need to fill in the information below.
S
You do not need to fill in the information below because [state Medicaid agency] has it.
Check here if this person has eligible immigration status and fill in the document type: _____________________________________________________________________________
and ID number: ______________________________ .
See Attachment D on page 13 for more information about eligible immigration status and document types.
Person 3
[Name]
Check here if
this person is
no longer living
in the household.
The [state agency name] has this person’s Social Security number.
The [state agency name] does not have this person’s Social Security number. Write it in the spaces below.
___
–
__
–
____
If this person is an immigrant, for their immigration status:
You need to fill in the information below.
You do not need to fill in the information below because [state Medicaid agency] has it.
Check here if this person has eligible immigration status and fill in the document type: _____________________________________________________________________________
and ID number: ______________________________ .
See Attachment D on page 13 for more information about eligible immigration status and document types.
Person 4
[Name]
Check here if
this person is
no longer living
in the household.
The [state agency name] has this person’s Social Security number.
The [state agency name] does not have this person’s Social Security number. Write it in the spaces below.
___
–
__
–
____
If this person is an immigrant, for their immigration status:
You need to fill in the information below.
You do not need to fill in the information below because [state Medicaid agency] has it.
Check here if this person has eligible immigration status and fill in the document type: _____________________________________________________________________________
and ID number: ______________________________ .
See Attachment D on page 13 for more information about eligible immigration status and document types.
Person 5
[Name]
Check here if
this person is
no longer living
in the household.
The [state agency name] has this person’s Social Security number.
The [state agency name] does not have this person’s Social Security number. Write it in the spaces below.
___
–
__
–
____
If this person is an immigrant, for their immigration status:
You need to fill in the information below.
You do not need to fill in the information below because [state Medicaid agency] has it.
Check here if this person has eligible immigration status and fill in the document type: _____________________________________________________________________________
and ID number: ______________________________ .
See Attachment D on page 13 for more information about eligible immigration status and document types.
Questions? Call [state agency] at 1-800-XXX-XXXX. The call is free. (TTY: 1-888-XXX-XXXX).
You can call [days and hours of operation]. Or visit <web address>.
3
?
4
We need more information about people
not listed in Section 3 (page 3)
Tell us about anybody else in your household or on your tax return.
Other person: Ernie Roberts
S
The [state agency name] has this person’s Social Security number.
The [state agency name] does not have this person’s Social Security number.
Write it here if this person is applying for health insurance coverage:
___
–
__
–
____
This person may choose not to give the Social Security number if
he or she is not applying, but it helps us to have it.
Check here if this person is no longer living in the household.
Date of birth (month/day/year): 9/15/1973
This person is:
S
Male
Female
How is this person related to you?
Check here if this person has Medicaid.
Check here if this person does not have Medicaid and wants health insurance coverage, and fill out Attachment A on page 10.
Other person: Name (first, middle, last & suffix):
The [state agency name] has this person’s Social Security number.
S
The [state agency name] does not have this person’s Social Security number.
Write it here if this person is applying for health insurance coverage:
___
–
__
–
____
This person may choose not to give the Social Security number if
he or she is not applying, but it helps us to have it.
Check here if this person is no longer living in the household.
Date of birth (month/day/year):
This person is:
Male
Female
How is this person related to you?
Check here if this person has Medicaid.
Check here if this person does not have Medicaid and wants health insurance coverage, and fill out Attachment A on page 10.
Other person: Name (first, middle, last & suffix):
The [state agency name] has this person’s Social Security number.
S
The [state agency name] does not have this person’s Social Security number.
Write it here if this person is applying for health insurance coverage:
___
–
__
–
____
This person may choose not to give the Social Security number if
he or she is not applying, but it helps us to have it.
Check here if this person is no longer living in the household.
Date of birth (month/day/year):
This person is:
Male
Female
How is this person related to you?
Check here if this person has Medicaid.
Check here if this person does not have Medicaid and wants health insurance coverage, and fill out Attachment A on page 10.
5
Tell us about other health insurance coverage people have
Include anyone in Sections 3 and 4 with Medicaid and anyone who is applying for health insurance coverage.
Name of insurance company:
Policy number:
Type of insurance:
Medicare
Tricare
Veteran's health coverage
Other insurance ___________________________________
List everyone who is on this policy:
Check here if anyone on this form is offered health insurance through a job, even if they are not enrolled in it.
Check here if any of the insurance plans you listed is a state employee benefit plan.
Name of insurance company:
Policy number:
Type of insurance:
Medicare
Tricare
Veteran's health coverage
Other insurance ___________________________________
List everyone who is on this policy:
Questions? Call [state agency] at 1-800-XXX-XXXX. The call is free. (TTY: 1-888-XXX-XXXX).
You can call [days and hours of operation]. Or visit <web address>.
4
?
6
Tell us more about the people listed on this form
If anyone who is renewing or applying for health insurance coverage has a medical,
mental health, or substance use condition that limits his or her ability to work, go to
school, or take care of daily activities (like bathing or dressing), write his or her name here.
Name (first, middle, last & suffix):
Name (first, middle, last & suffix):
If anyone who is renewing or applying for health insurance coverage lives in a long term care
facility, group home, or nursing home, or regularly gets medical care, personal care, or health
services at home or in another community setting (like adult day care), write his or her name here.
Name (first, middle, last & suffix):
Name (first, middle, last & suffix):
If anyone who is renewing or applying for health insurance coverage is blind or terminally ill,
write his or her name here.
Name (first, middle, last & suffix):
Name (first, middle, last & suffix):
If anyone who is renewing or applying for health insurance coverage is between the ages
of 18 and 22 and is also a full-time student, write his or her name here.
Name (first, middle, last & suffix):
Name (first, middle, last & suffix):
If anyone who is renewing or applying for health insurance coverage is between the ages
of 18 and 26 and was in foster care at age 18, write his or her name here.
Name (first, middle, last & suffix):
Name (first, middle, last & suffix):
If anyone listed on this form (whether renewing or applying for health insurance coverage or not)
is pregnant, write her information below.
Name (first, middle, last & suffix): How many babies are expected?
Name (first, middle, last & suffix): How many babies are expected?
Check here if anyone who is renewing or applying for health insurance coverage is
an American Indian or Alaska Native, and fill out Attachment B on page 11.
Questions? Call [state agency] at 1-800-XXX-XXXX. The call is free. (TTY: 1-888-XXX-XXXX).
You can call [days and hours of operation]. Or visit <web address>.
5
?
7
Tell us about work
Fill in the information below for everyone in your household or on your tax return who has income from
a job (not self-employed) whether or not they are renewing or applying for coverage. If someone has
more than one job, tell us about all jobs. You can tell us about self-employment on the next page.
Make a copy of this page if you need space for more jobs or people. Cross out any information that is
not correct about members of your household. Write in any new information.
Job 1: Name of the person who is working (first, middle, last & suffix): Ernie Roberts
Employer name:
Joe's Body Shop
Employer phone number:
123-456-7890
Employer address: City: State: ZIP code:
123 Main St, Anywhere, ST 01234
How often are wages or tips paid?
Hourly
Every two weeks
Monthly
Weekly
S
Twice a month
Yearly
How much does this person get paid (before taxes)? $ 417
Average hours worked each week:
Job 2: Name of the person who is working (first, middle, last & suffix):
Employer name:
Employer phone number:
Employer address: City: State: ZIP code:
How often are wages or tips paid?
Hourly
Every two weeks
Monthly
Weekly
Twice a month
Yearly
How much does this person get paid (before taxes)? $ ____________________________________________________________________
Average hours worked each week:
Job 3: Name of the person who is working (first, middle, last & suffix):
Employer name:
Employer phone number:
Employer address: City: State: ZIP code:
How often are wages or tips paid?
Hourly
Every two weeks
Monthly
Weekly
Twice a month
Yearly
How much does this person get paid (before taxes)? $ ____________________________________________________________________
Average hours worked each week:
Job 4: Name of the person who is working (first, middle, last & suffix):
Employer name:
Employer phone number:
Employer address: City: State: ZIP code:
How often are wages or tips paid?
Hourly
Every two weeks
Monthly
Weekly
Twice a month
Yearly
How much does this person get paid (before taxes)? $ ____________________________________________________________________
Average hours worked each week:
Job 5: Name of the person who is working (first, middle, last & suffix):
Employer name:
Employer phone number:
Employer address: City: State: ZIP code:
How often are wages or tips paid?
Hourly
Every two weeks
Monthly
Weekly
Twice a month
Yearly
How much does this person get paid (before taxes)? $ ____________________________________________________________________
Average hours worked each week:
Section 7 continued on next page
Questions? Call [state agency] at 1-800-XXX-XXXX. The call is free. (TTY: 1-888-XXX-XXXX).
You can call [days and hours of operation]. Or visit <web address>.
6
?
7
Tell us about work (continued)
If anyone in your household is self-employed, we need to know about their work.
See the instructions for more information about deductions.
1. Name (first, middle, last & suffix):
Type of work:
How much net income will this person get from self-employment this month? Amount: $ __________________________________________________________________
2. Name (first, middle, last & suffix):
Type of work:
How much net income will this person get from self-employment this month? Amount: $ __________________________________________________________________
List anyone in your household who has changed jobs or has worked fewer hours in the past four months.
1. Name (first, middle, last & suffix):
This person stopped working
This person is now working fewer hours
This person changed jobs
2. Name (first, middle, last & suffix):
This person stopped working
This person is now working fewer hours
This person changed jobs
8
Tell us about other income
Cross out any information that is not correct about members of your household. Write in any new information.
Unemployment How much? How often?
Name (first, middle, last & suffix):
Samantha Roberts
$
70
S
Weekly
Every two weeks
Yearly
Monthly
Twice a month
Other________________
Social Security
How much? How often?
Name (first, middle, last & suffix):
$
Weekly
Every two weeks
Yearly
Monthly
Twice a month
Other________________
Pensions How much? How often?
Name (first, middle, last & suffix):
$
Weekly
Every two weeks
Yearly
Monthly
Twice a month
Other________________
Retirement accounts
Name (first, middle, last & suffix):
$
Weekly
Every two weeks
Yearly
Monthly
Twice a month
Other________________
Section 8 continued on next page
Subtract the expenses below from your gross income to get an amount for your net self-employment income.
Car and truck expenses (for travel during the workday, not commuting)
Depreciation
Employee wages and fringe benefits
Property, liability, or business interruption insurance
Interest (including mortgage interest paid to banks, etc.)
Legal and professional services
Rent or lease of business property and utilities
Commissions, taxes, licenses and fees
Advertising
Contract labor
Repairs and maintenance
Certain business travel and meals
Deductible self-employment taxes
Cost of self-employed health insurance
Contributions to a self-employed SEP, SIMPLE, or qualified
retirement plan
Questions? Call [state agency] at 1-800-XXX-XXXX. The call is free. (TTY: 1-888-XXX-XXXX).
You can call [days and hours of operation]. Or visit <web address>.
7
?
Other income
Type: _________________________________________________ How much? How often?
Name (first, middle, last & suffix):
$
Weekly
Every two weeks
Yearly
Monthly
Twice a month
Other________________
Other income
Type: _________________________________________________ How much? How often?
Name (first, middle, last & suffix):
$
Weekly
Every two weeks
Yearly
Monthly
Twice a month
Other________________
If anyone in your household has deductions, tell us what kind.
Alimony paid to someone else
How much? How often?
Name (first, middle, last & suffix):
$
Weekly
Every two weeks
Yearly
Monthly
Twice a month
Other________________
Student loan interest paid
How much?
How often?
Name (first, middle, last & suffix):
$
Weekly
Every two weeks
Yearly
Monthly
Twice a month
Other________________
Other deductions
How much? How often?
Name (first, middle, last & suffix):
$
Weekly
Every two weeks
Yearly
Monthly
Twice a month
Other________________
8
Tell us about other income (continued)
Cross out any information that is not correct about members of your household. Write in any new information.
Alimony received
How much? How often?
Name (first, middle, last & suffix):
$
Weekly
Every two weeks
Yearly
Monthly
Twice a month
Other________________
Farming or fishing (profit after business expenses) How much? How often?
Name (first, middle, last & suffix):
$
Weekly
Every two weeks
Yearly
Monthly
Twice a month
Other________________
Rental income or royalties (profit after business expenses)
How much? How often?
Name (first, middle, last & suffix):
$
Weekly
Every two weeks
Yearly
Monthly
Twice a month
Other________________
List the names of anyone whose income changes from month to month. Also tell us how much you think
their income will be for the year. Make a copy of this page if you need space for more people.
1. Name (first, middle, last & suffix):
What do you expect his or her income to be this year? Amount:
$
Check here if you do not know what the income will be
this year
.
2. Name (first, middle, last & suffix):
What do you expect his or her income to be this year? Amount:
$
Check here if you do not know what the income will be
this year
.
3. Name (first, middle, last & suffix):
What do you expect his or her income to be this year? Amount:
$
Check here if you do not know what the income will be
this year
.
Questions? Call [state agency] at 1-800-XXX-XXXX. The call is free. (TTY: 1-888-XXX-XXXX).
You can call [days and hours of operation]. Or visit <web address>.
8
?
Renewal of coverage in future years
Read the statement below and check one box.
To make it easier to check my income at renewal time, I give permission to the [state agency] to use income
information from my tax returns for the number of years I checked below.
I understand that the [state agency] will send me a letter with the income information they have. I can make
changes to it. I can also change my mind and not allow the [state agency] to check this information.
Yes, I give permission to check my income on tax returns for (check one box):
5 years (the longest time)
4 years
3 years
2 years
1 year
No, I do not give permission to use my tax returns.
Your rights and responsibilities
I am signing this renewal form under penalty of perjury.
That means that I have provided true answers to all
the questions on this form to the best of my knowledge,
and I know that I may be subject to penalties under
federal law if I provide false or untrue information.
I know that I must tell [state agency] if anything changes
and is different from what I wrote on this form. I can
call XXX-XXX-XXXX or visit [web address] to report any
changes. I understand that a change in my information
might affect whether someone in my household
qualifies for coverage.
I know that under federal law, discrimination is not
permitted on the basis of race, color, national origin,
sex, age, sexual orientation, gender identity, or disability.
I can file a complaint of discrimination by visiting
hhs.gov/ocr/office/file.
If I think [state agency] has made a mistake, I can appeal
its decision. To appeal means to tell someone at [state
agency] that I think the action is wrong, and ask for a
fair review of the action. I know that I can find out how
to appeal by contacting [state agency] at XXX-XXX-XXXX.
Someone from [state agency] will explain anything about
this application to me if I need that.
I understand that if I do not qualify for Medicaid, [state
agency] will check to see if I qualify for other kinds of health
coverage. [State agency] may send my information to
another program so they can see if I qualify. [State agency]
will check my answers using information from computer data
sources, including the Internal Revenue Service (IRS), the
Social Security Administration, the Department of Homeland
Security and others. If the information does not match,
[state agency] may ask me to send more information.
I understand that, after my death, [state agency] can file a
claim against my estate to recover money that the state paid
for coverage provided to me. This process must happen
if I am in a medical institution and not expected to return
home, or if I am 55 years of age or older and the state pays
for my nursing facility services, home and community based
services, or related hospital and prescription drug services.
The amount recovered by the [state agency] will not be
more than the amount Medicaid paid for my care.
I understand that when I send in this form, it means I have
permission from everyone whose information is on the form
to submit their information to [state agency] and receive any
communications about their eligibility and enrollment.
I understand that [state agency] is authorized to collect
information on this form, and other supporting information
including Social Security numbers, under the Patient
Protection and Affordable Care Act (Public Law No. 111-148),
as amended by the Health Care Education Reconciliation Act
of 2010 (Public Law 111-152) and the Social Security Act.
Sign and date below. If you want an authorized representative or want to change the authorized
representative you have now, fill out Attachment C on page 12.
Check here if you are an authorized representative. Sign below and fill out Attachment C on page 12.
Signature of household contact or authorized representative:
Date:
9
Read and sign this application
Questions? Call [state agency] at 1-800-XXX-XXXX. The call is free. (TTY: 1-888-XXX-XXXX).
You can call [days and hours of operation]. Or visit <web address>.
9
?
Tell us more information about this person
Check here, if this person lives with at least one child under the age of 19, and is the main person taking care of this child.
Check here, if this person is 18 years or younger and has a parent living outside of the household.
Check here, if this person wants help paying for medical bills from the last three months.
Tell us more information about this person
Check here, if this person lives with at least one child under the age of 19, and is the main person taking care of this child.
Check here, if this person is 18 years or younger and has a parent living outside of the household.
Check here, if this person wants help paying for medical bills from the last three months.
Attachment A
People applying for Medicaid for the first time
For people listed in Section 4, Page 4
Tell us about anyone in your household who wants to apply for Medicaid. Do not answer these questions for people
who already have Medicaid. If more than two people are applying, make a copy of this page.
Name of person applying:
Name (first, middle, last & suffix)
Tell us about citizenship
Is this person a U.S. citizen or U.S. national?
Yes If yes, go to "Tell us more information about this person"
No If no, answer all of the questions below.
Check here, if this person has eligible immigration status and fill in the document type: __________________________________________________________________________
and ID number: __________________________. See Attachment D on page 13 for more information about eligible immigration status and document types.
Check here, if this person has lived in the U.S. since 1996.
Check here, if this person, his or her spouse, or a parent is a veteran or an active duty member in the U.S. military.
Name of person applying:
Name (first, middle, last & suffix)
Tell us about citizenship
Is this person a U.S. citizen or U.S. national?
Yes If yes, go to "Tell us more information about this person"
No If no, answer all of the questions below.
Check here, if this person has eligible immigration status and fill in the document type: __________________________________________________________________________
and ID number: __________________________. See Attachment D on page 13 for more information about eligible immigration status and document types.
Check here, if this person has lived in the U.S. since 1996.
Check here, if this person, his or her spouse, or a parent is a veteran or an active duty member in the U.S. military.
Tell us about race and ethnicity. You may choose not to answer these questions.
If this person is Hispanic/Latino,
check all that apply:
Mexican
Mexican American
Chicano/a
Puerto Rican
Cuban
Other ____________
What is this person’s race? Check all that apply:
White
Black or African
American
American Indian or
Alaska Native
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander
Other _____________________
Tell us about race and ethnicity. You may choose not to answer these questions.
If this person is Hispanic/Latino,
check all that apply:
Mexican
Mexican American
Chicano/a
Puerto Rican
Cuban
Other ____________
What is this person’s race? Check all that apply:
White
Black or African
American
American Indian or
Alaska Native
Asian Indian
Chinese
Filipino
Japanese
Korean
Vietnamese
Other Asian
Native Hawaiian
Guamanian or Chamorro
Samoan
Other Pacific Islander
Other _____________________
If anyone applying for Medicaid has medical bills from the last three months, send the medical bills to
<Billing Office>, [Medicaid Agency], [100 State Street], [Anycity, State]. Medicaid may pay past bills, even if you already paid them yourself.
Questions? Call [state agency] at 1-800-XXX-XXXX. The call is free. (TTY: 1-888-XXX-XXXX).
You can call [days and hours of operation]. Or visit <web address>.
10
?
Attachment B
American Indian or Alaska Native family
member (AI/AN) To help you fill out Section 6, page 5
Tell us about your American Indian or Alaska Native family member(s)
American Indians and Alaska Natives can get services from the Indian Health Services, tribal health programs, or urban
Indian health programs. They may not have to pay co-pays and may get special monthly enrollment periods.
If more than two people are American Indian or Alaska Native, make a copy of this page.
1. Name (first, middle, last & suffix):
Has this person ever received a service from the Indian Health Service, a tribal health program, or urban Indian health program?
Yes
No
If no, does this person qualify to get these services?
Yes
No
List any income that includes money from these sources:
Payments from a tribe for natural resources, usage rights, leases, or royalties
Payments from natural resources, farming, ranching, fishing, leases, or royalties from
land designated as Indian trust land by the Department of Interior (including reservations and
former reservations)
Money from selling things that have cultural significance
How much income? $
How often?
Weekly
Twice a month
Every two weeks
Yearly
Monthly
2. Name (first, middle, last & suffix):
Has this person ever received a service from the Indian Health Service, a tribal health program, or urban Indian health program?
Yes
No
If no, does this person qualify to get these services?
Yes
No
List any income that includes money from these sources:
Payments from a tribe for natural resources, usage rights, leases, or royalties
Payments from natural resources, farming, ranching, fishing, leases, or royalties from
land designated as Indian trust land by the Department of Interior (including reservations and
former reservations)
Money from selling things that have cultural significance
How much income? $
How often?
Weekly
Twice a month
Every two weeks
Yearly
Monthly
Questions? Call [state agency] at 1-800-XXX-XXXX. The call is free. (TTY: 1-888-XXX-XXXX).
You can call [days and hours of operation]. Or visit <web address>.
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