SIGNATURE OF APPLICANT:
SIGNATURE OF APPLICANT: DATE: HOME ADDRESS: __________________________________ MAILING ADDRESS: ________________________________________________ PREGNANT: DISABLED: AGED: TANF: FOSTER CARE: FORMER FOSTER CARE: EMANCIPATED MINOR: Check If No Fixed Address GOVERNMENT OF THE VIRGIN ISLANDS Department of Human Services "Working Together to Make a Difference" MEDICAL ASSISTANCE PROGRAM STATEMENT OF FACTS YOU MUST COMPLETE ALL FIELDS ON THIS APPLICATION TO RECEIVE A TIMELY ELIGIBILITY DETERMINATION MAP CASE NO: HOUSEHOLD COMPOSITION NAME DATE OF BIRTH SEX RACE* RELATIONSHIP TO APPLICANT SOCIAL SECURITY NUMBER INCOME TYPE (Earnings, Social Security, Unemployment, etc.) RESOURCE(S) Saving, Checking, Property) HEALTH INSURANCE PROVIDER *Race Codes: 1=White or Caucasian, 2=Black or African American, 3=Native Alaskan or American Indian, 11=Asian, 16=Hawaiian, Pacific Islander, 17=Decline to Answer, 18=Other I certify through my signature that the answers given are true and correct to the best of my knowledge and belief. …
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SIGNATURE OF APPLICANT: DATE: HOME ADDRESS: __________________________________ MAILING ADDRESS: ________________________________________________ PREGNANT: DISABLED: AGED: TANF: FOSTER CARE: FORMER FOSTER CARE: EMANCIPATED MINOR: Check If No Fixed Address GOVERNMENT OF THE VIRGIN ISLANDS Department of Human Services "Working Together to Make a Difference" MEDICAL ASSISTANCE PROGRAM STATEMENT OF FACTS YOU MUST COMPLETE ALL FIELDS ON THIS APPLICATION TO RECEIVE A TIMELY ELIGIBILITY DETERMINATION MAP CASE NO: HOUSEHOLD COMPOSITION NAME DATE OF BIRTH SEX RACE* RELATIONSHIP TO APPLICANT SOCIAL SECURITY NUMBER INCOME TYPE (Earnings, Social Security, Unemployment, etc.) RESOURCE(S) Saving, Checking, Property) HEALTH INSURANCE PROVIDER *Race Codes: 1=White or Caucasian, 2=Black or African American, 3=Native Alaskan or American Indian, 11=Asian, 16=Hawaiian, Pacific Islander, 17=Decline to Answer, 18=Other I certify through my signature that the answers given are true and correct to the best of my knowledge and belief. I realize that deliberate misrepresentation or concealment of facts may constitute fraud for which I may lose my Medical Assistance coverage or can be prosecuted for a crime. Information provided by you will be disclosed with your application to SGRX, and the selected insurance carrier for the administration of your enrollment and premium payments. You authorize SGRX to access, prepare and submit insurance applications on your behalf, and authorize SGRX to communicate with you via telephone, text message (SMS) and/or e-mail using the contact information you provide to us. APPLICANT: ______________________________________ MARITAL STATUS: ______ BIRTH DATE: ______________ SSN: ___________________________ MOBILE PHONE: ( )________________________________HOME PHONE: ( )_____________________________WORK PHONE: ( )_________________ EMAIL: ____________________________________________________ PREFERRED METHOD OF CONTACT :______________________________________