Hospital Application for Presumptive Eligibility for Medicaid
Hospital Application for Presumptive Eligibility for Medicaid 1 Tell us about yourself (Primary household member) Gender: Male Female We ask for this information so that we can contact you about this application. Name (first, middle, last) Social Security Number (SSN) (Not required for PE determination) Date of Birth (MM/DD/YYYY) Home address (Indicate “NONE” if you do not have one) City, State, Zip code Mailing address (if different from home address) Phone number (if you have one) Email address (if you have one) 2 Tell us about your family List the members of your immediate family who live with you. Include your spouse and your children under age 19 if they live with you. Do not list other relatives or friends even if they live with you. Name (first, middle, last) D.O.B. (MM/DD/YYYY) Social Security Number (SSN) (Not required for PE determination) Relationship to you Already has Medicaid? (Yes or No) Applying for PE? (Yes or No) U.S. Citizen, U.S. National, or eligible immigrant? (Yes or No) Resident of the Territory? …
Download the original document · Plain text (TXT) · Browse the archive · How this archive works
Original source: https://dhs.vi.gov/wp-content/uploads/2023/03/MAP_USVI-Hospital-PE-Application-v3-11-13-2018.pdf
SHA-256 f3e716954afbd670b8390f2c7ab2d65856073a6941bf8e7fc3785573152ccbd5
Re-using this document
territorial public record
Our description, tagging, arrangement, extracted text and machine transcripts are released under CC0 1.0. We assert nothing about the document itself.
Archive identifier LF-f3e716954afb
Document text
Hospital Application for Presumptive Eligibility for Medicaid 1 Tell us about yourself (Primary household member) Gender: Male Female We ask for this information so that we can contact you about this application. Name (first, middle, last) Social Security Number (SSN) (Not required for PE determination) Date of Birth (MM/DD/YYYY) Home address (Indicate “NONE” if you do not have one) City, State, Zip code Mailing address (if different from home address) Phone number (if you have one) Email address (if you have one) 2 Tell us about your family List the members of your immediate family who live with you. Include your spouse and your children under age 19 if they live with you. Do not list other relatives or friends even if they live with you. Name (first, middle, last) D.O.B. (MM/DD/YYYY) Social Security Number (SSN) (Not required for PE determination) Relationship to you Already has Medicaid? (Yes or No) Applying for PE? (Yes or No) U.S. Citizen, U.S. National, or eligible immigrant? (Yes or No) Resident of the Territory? (Yes or No) 3 Other questions Answer these questions for yourself and any family members listed in Section 2. Your answers will make it easier to find out if you and any family members qualify. Is anyone pregnant, even if she is not applying for presumptive eligibility for Medicaid? Yes No If yes, who? .................................................................................................................................... Expected due date? ……………………………………………… How many babies does she expect? ...................... Application for Presumptive Eligibility for Medicaid Is anyone who is applying for presumptive eligibility for Medicaid a parent or caretaker relative? Yes No For example, a grandparent who is the main person taking care of a child. If yes, who? ..................................................................................................................... Is anyone who is applying for presumptive eligibility a former foster care child who is currently under the age of 26? Yes No If yes, who? ................................................................... ................................. What age did the claimant leave the foster care system? ........................................................... Was the Claimant enrolled on Medicaid at the time they aged out? Yes No 4 Tell us about your family’s income Write the total income before taxes are taken out for all family members listed in Section 2. Job income For example, wages, salaries, and self-employment income. Amount $................... Employer/Address.................................................................................................................... How often? (check one) Weekly Biweekly Monthly Yearly Hours ……………. Date began ............................. Other income For example, unemployment checks, alimony, or disability payments from the Social Security Administration (“SSDI”). Do not include any child support you receive. Amount $..................... Type of Benefit ..................................................................................................................... How often? (check one) Weekly Biweekly Monthly Yearly Date began ........................................................ 5 Sign this form here (optional) We will keep your information secure and private. Your signature (optional): Date: Hospital Representative Signature Date: