Y-03-00021523286J-20110513-NÌY0300021523286J20110513NeÎ MAIL TO: Mail Renewal Program HRA/Medical Assistance Program PO Box 329060 Brooklyn, NY 11232-9823 MEDICAID/FAMILY HEALTH PLUS (FHPlus) RENEWAL FORM LOCATION: 24 NOTICE DATE: CASE NUMBER: 00021523286J NUMBER OF ADULTS: 1 NUMBER OF CHILDREN: 0 PRIORITY: N RVI CODE: Carefully read the "guide booklet" that came with this form before you begin to answer any questions. To allow us to determine if you can continue receiving Medicaid/Family Health Plus (FHPlus), you must: 1. Answer all questions on this form. 2. Look for instructions about sending proof in each section of the form. If the instructions tell you to send proof (documentation) or the level of coverage you need requires you to send proof, see the enclosed Documentation Guide for a list of the proofs that we accept. 3. Return this form and all needed proofs (documents) in the enclosed envelope. If we do not receive this form and the needed proofs in our office before 05/13/2011 your Medicaid/FHPlus will end. 01 02 03 04 05 06 07 08 09 10 11 12 () HOUSEHOLD: • If someone has left the household, cross-out her/his name. • If "Add SSN" is printed in the Social Security Number (SSN) column for any person, write-in the SSN. ° If that person does have a SSN, send the most current dated form SSA-5028 from the Social Security Administration (SSA) or a signed letter from SSA confirming that the person applied for a SSN. ° If that person is pregnant, write "pregnant." • If "Send Proof" is printed in the Citizenship/Immigration Status column, send the most recent letter from the United States Citizenship and Immigration Services (USCIS) or proof of current citizenship/immigration status. Citizenship/ Date of Sex Social Security No Name Immigration Birth (M/F) Number (SSN) Change Status GIANCARLOS PEREZ 03-06-1987 M Number on File [] [] [] [] [] [] [] [] [] [] [] [] X Indicates additional members are on the case. RESIDENCE AND TELEPHONE NUMBER: Is the address and telephone number printed below correct? • If it is correct, check the "No Change" box. • If it is not correct, write-in the most current information. • If you need long term care services, Send Proof of your address if you are changing what is printed below. No Change Address:4520 BROADWAY 3F NEW YORK NY 10040 _____________________________________ [] Phone Number: (347)235-1037 [] MAP - 2096F (English) Rev. 03/10/09 Page:1 of 4 or spouse of those listed in Section . certified blind or certified disabled. trust funds. etc. the person providing the support must complete and sign the Declaration of Support located on Page 4 of this booklet. Send Proof of employment." Otherwise. Send copy of front and back of health insurance card for each person who has other health insurance. If none. If either or both of the following apply to you. I get paid/tips in cash. Child Health Plus or Family Planning Benefit Program coverage Send Proof of any other health care premium expenses other than Medicare.2096F (English) Rev.INCOME: Write-in income information for anyone listed in Section and anyone in the household who is a parent. check "Yes. step-parent. If you are currently enrolled in or are applying for the Medicaid Buy-In for Working People with Disabilities (MBI-WPD) program. 03/10/09 Page:2 of 4 . Send Proof of the resources that you/they have. such as a home or personal care services. ownership of a buisness. I cannot get a letter from my employer and I did not file a tax return last year. check "Yes." . certificates of deposit. . You must also sign that section. bonds.) Are you currently enrolled in or are applying for the Medicaid Buy-In for Working People with Disabilities (MBI-WPD) program? ☐ Yes ☐ No ☐ Yes ☐ No IMPORTANT NOTE: You only need to complete this section if you or someone on your case is age 65 or over." . provide the following: Name of spouse or parent: Address of spouse or parent: Name of related household member: Name of Insurer: _____________________________________ _____________________________________ _____________________________________ Premium Amount (if known) $ How Often Paid MAP . I am supported by another person. real estate/real property other than your primary residence. check "No. if you havenot submitted it before. If you need long term care services or if you may be eligible for Medicaid with a surplus (Excess Income Program) Send Proof of income. Type of Name of Employer (if Amount (before How Often (weekly/biName Income income is from employment) taxes and deductions) weekly/monthly) $ $ $ $ If all of the following applies to you. write "0. saving and checking accounts." Otherwise. check "No. . (If you are supported by someone else. I have no income." ☐ Yes ☐ No . Does anyone on this case have a spouse or parent who can provide health insurance for them? ☐Yes ☐No If so. RESOURCES: Cash on hand. Do notlist persons who only have Medicaid. . . Type of Resource Amount OTHER HEALTH INSURANCE: Tell us if anyone on this case has other health insurance. stocks. Family Health Plus. I do not get paychecks/pay stubs. If you need long term care services. . Write in the name(s) of the person(s) with the resources that you/they have. liens or other debts against the home) more than $750. do they have to pay special expenses (non-medical) in order to work? ☐Yes If "yes". Name Expenses How Often EXPENSES: Write-in how much you pay for housing/rent and for childcare/dependent care. Signature of Consumer:_________________________________ SIGN HERE Signature of other Adult in Household (if applicable):______________ Signature of Representative (if applicable):______________________ TO BE COMPLETED BY THE MEDICAL ASSISTANCE PROGRAM Date Date:___________ Date:___________ Date:___________ Worker Signature Supervisor Signature Date MAP . ☐No Send Proof of special expenses paid in order to work. Name of pregnant woman: Expected date of delivery Send Proof If anyone on this case is blind or disabled. I have also read and understand the Terms Rights and Responsibilities. If you need long term care services or if you may be eligible for Medicaid with a surplus Send Proof of childcare/dependent care expenses.PREGNANCY AND DISABILITY: Tell us if anyone listed in Section is pregnant. 03/10/09 Page:3 of 4 . (Pregnant women do not need to provide SSN or prove immigration status. Housing/Rent: $ How Often: Childcare/Dependent care: $ How Often: HOME EQUITY: You only need to complete this section if you need long-term care services. is your home equity (market value of home or the portion of the home that you own less all outstanding mortgages. send statement from medical provider verifying pregnancy and expected date of delivery.2096F (English) Rev. Do You Own or Co-Own Your Home? ☐Yes ☐No If "Yes".000? ☐Yes ☐No LANGUAGE: What language do you prefer to read?________________What language do you prefer to speak?_________ OTHER PEOPLE IN HOUSEHOLD: Write in the name of anyone in the household who is not on this case and tell us what their relationship is to person(s) listed in section Name of Person Age Name of Person in Section Relationship I certify under penalty of perjury that everything on this application is the truth as best I know.) Is anyone on this case pregnant? If so. SUPPORT To be completed by the person who provides support. SIGN HERE Signature of Consumer: ___________________ Date: ___________ MAP . I undertand that program officials may verify all information on this form. Please complete this section so that the Medical Assistance Program can determine eligibility for Public Health Insurance. 03/10/09 Page:4 of 4 . Name: (Print)____________________________Address: _____________________________ Phone Number:______________Relationship to person you provide support: ______________ I provide the following: (Check all that apply) ☐ Sleeping accommadations ☐ Meals ☐ Monthly cash assistance $_________________ ☐ Other (explain)___________________________________________________________ I have provided the support since_______ and (Check one) ☐ I will continue to do so ☐I will not continue to do so Do you pay medical and/or hospital expenses for this person? (Check one) SIGN HERE ☐ Yes ☐ No _______________ Date: Name of person providing support: ___________ Consumer must read the following and sign below.2096F (English) Rev.