Statement of Circumstances
Statement of Circumstances For use with Medicaid applications Applicant Name Case Number Date Date of Birth Home Address Mailing Address Phone Number Email Please use this form to provide additional information, clarification, or explanation related to your Medicaid application. Client Signature Date Client Printed Name OR Disclaimer: We do not discriminate on the basis of race, ethnicity, color, national origin, religion, sex, age, or disability. Free language assistance services are available for people whose primary language is not English. We also provide free aids and services to assist with communicating the information effectively (such as interpreters, captioning, Braille, or large print). If you need these services, please contact us by phone or email. St Thomas/St. John District: 340-774-0930 ext. 4104 or sttjmap@dhs.vi.gov | St. Croix: 340-772-7100 or stxmap@dhs.vi.gov Privacy Notice: The information provided on this form will be used only for purposes of determining and verifying Medicaid eligibility. Your information is protected under state and federal privacy laws. …
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Statement of Circumstances For use with Medicaid applications Applicant Name Case Number Date Date of Birth Home Address Mailing Address Phone Number Email Please use this form to provide additional information, clarification, or explanation related to your Medicaid application. Client Signature Date Client Printed Name OR Disclaimer: We do not discriminate on the basis of race, ethnicity, color, national origin, religion, sex, age, or disability. Free language assistance services are available for people whose primary language is not English. We also provide free aids and services to assist with communicating the information effectively (such as interpreters, captioning, Braille, or large print). If you need these services, please contact us by phone or email. St Thomas/St. John District: 340-774-0930 ext. 4104 or sttjmap@dhs.vi.gov | St. Croix: 340-772-7100 or stxmap@dhs.vi.gov Privacy Notice: The information provided on this form will be used only for purposes of determining and verifying Medicaid eligibility. Your information is protected under state and federal privacy laws. FOR OFFICE USE ONLY Received by: Date: Client Prejury Statement: Under penalty of perjury, I certify that the information presented in this document is true and accurate to the best of my knowledge. By signing below, I understand that providing false statements may result in termination, denial, or recovery of benefits. Authorized Representative Signature Phone Number Email Authorized Representative Name Date SIGN SIGN SIGN