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MedicaidRenewal FormMary Smith123 Smith StreetSmithtown, FL 00000You can get this notification in another languageor in large print or another way that’s best for you.Call 1-800-XXX-XXXX (TTY: 1-888-XXX-XXXX).November 5, 2013Respond by: December 12, 2013Letter number: 34567It is time to renew your Medicaid coverage.You can renew yourMedicaid in anyone 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. onSaturday.How to completethis renewal form1. Answer all of the questions on the form.2. Read the information about you and each member of your household. Add anymissing 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 thisdeadline, you will lose your Medicaid coverage.What we needWe need information about each person living in your household or listed onyour 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 notmatch, we may ask you to send more information.If you do not qualifyfor Medicaid?If you do not qualify for Medicaid, [state agency] will check to see if you qualifyfor other kinds of health coverage. [State agency] may send your information toanother program so they can see if you qualify.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

1Your contact information Review your contact information here. Correct any wrong or missing information here.Name (first, middle, last & suffix)Ernie RobertsHome addressApartment #Home address:1234 America Ave. Apt. 1ACity (home)StateZIP codeAnywhere, ST 12345Mailing address:Mailing addressApartment #5678 Broad St.City (mailing)P.O. Box 6789StateZIP codeAnywhere, ST 12345Best phone number to reach you:Phone:Home: 111-222-3333Other: Home Cell WorkNumber:Other phone number, if you have one: Home Cell WorkNumber:Email address, if you have one:2We 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? YesIf yes, answer all of the questions below. NoIf no, answer the question marked with a star belowPerson 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 householdIf 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 filerand the dependents. Answer only if different than what you reported above or if you did not fill in anyinformation 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

These are the people in your household whoget Medicaid and need to renew now3Person 1Samantha RobertsS The [state agency name] has this person’s Social Security number. T he [state agency name] does not have this person’s Social Security number. Write it in the spaces below.– – Check here ifthis person isno longer livingin the household.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 2Benjamin Roberts The [state agency name] has this person’s Social Security number.S T he [state agency name] does not have this person’s Social Security number. Write it in the spaces below.– – Check here ifthis person isno longer livingin the household.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] The [state agency name] has this person’s Social Security number. T he [state agency name] does not have this person’s Social Security number. Write it in the spaces below.– – Check here ifthis person isno longer livingin the household.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] The [state agency name] has this person’s Social Security number. T he [state agency name] does not have this person’s Social Security number. Write it in the spaces below.– – Check here ifthis person isno longer livingin the household.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] The [state agency name] has this person’s Social Security number. T he [state agency name] does not have this person’s Social Security number. Write it in the spaces below.– – Check here ifthis person isno longer livingin the household.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

We need more information about peoplenot listed in Section 3 (page 3)4 Tell us about anybody else in your household or on your tax return.Ernie RobertsOther person:S The [state agency name] has this person’s Social Security number. Check here if this person is no longer living in the household. 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 ifhe or she is not applying, but it helps us to have it.Date of birth (month/day /year): 9/15/1973This person is: S Male FemaleHow 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. Check here if this person is no longer living in the household.S T he [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 ifhe or she is not applying, but it helps us to have it.Date of birth (month/day /year):This person is: Male FemaleHow 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. Check here if this person is no longer living in the household.S T he [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 ifhe or she is not applying, but it helps us to have it.Date of birth (month/day /year):This person is: Male FemaleHow 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 10.5Tell 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:Type of insurance: MedicarePolicy number: Tricare Veteran's health coverage Other insuranceList everyone who is on this policy:Name of insurance company:Type of insurance: MedicarePolicy number: Tricare Veteran's health coverage Other insuranceList 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.?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

6Tell 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 toschool, 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 carefacility, group home, or nursing home, or regularly gets medical care, personal care, or healthservices 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 agesof 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 agesof 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 isan 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

7Tell us about work Fill in the information below for everyone in your household or on your tax return who has income froma job (not self-employed) whether or not they are renewing or applying for coverage. If someone hasmore 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 isnot 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 RobertsEmployer phone number:Employer name:123-456-7890Joe's Body ShopEmployer address:City:State:ZIP code:123 Main St, Anywhere, ST 01234How often are wages or tips paid? HourlyHow much does this person get paid (before taxes)? Every two weeks 417 Monthly WeeklyS Twice a month YearlyAverage hours worked each week:Job 2: Name of the person who is working (first, middle, last & suffix):Employer phone number:Employer name:Employer address:How often are wages or tips paid?City: HourlyHow much does this person get paid (before taxes)? Every two weeks MonthlyState: Weekly Twice a month ZIP code: YearlyAverage hours worked each week:Job 3: Name of the person who is working (first, middle, last & suffix):Employer phone number:Employer name:Employer address:How often are wages or tips paid?City: HourlyHow much does this person get paid (before taxes)? Every two weeks MonthlyState: Weekly Twice a month ZIP code: YearlyAverage hours worked each week:Job 4: Name of the person who is working (first, middle, last & suffix):Employer phone number:Employer name:Employer address:How often are wages or tips paid?City: HourlyHow much does this person get paid (before taxes)? Every two weeks MonthlyState: Weekly Twice a month ZIP code: YearlyAverage hours worked each week:Job 5: Name of the person who is working (first, middle, last & suffix):Employer phone number:Employer name:Employer address:How often are wages or tips paid?City: HourlyHow much does this person get paid (before taxes)? Every two weeks MonthlyState: Weekly Twice a month ZIP code: YearlyAverage 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

7Tell us about work (continued) 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 working2. This person is now working fewer hours This person changed jobs This person is now working fewer hours This person changed jobsName (first, middle, last & suffix): This person stopped working 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: Subtract the expenses below from your gross income to get an amount for your net self-employment income. Carand truck expenses (for travel during the workday, not commuting) Advertising Depreciation Contract Employee Repairsand maintenance Certainbusiness travel and mealswages 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 fees8labor Deductible Costself-employment taxesof self-employed health insurance Contributionsto a self-employed SEP, SIMPLE, or qualifiedretirement planTell us about other income Cross out any information that is not correct about members of your household. Write in any new information.UnemploymentHow much?How often?Name (first, middle, last & suffix): S Weekly MonthlySamantha Roberts70 Every two weeks Yearly Twice a month OtherSocial SecurityHow much?How often?Name (first, middle, last & suffix): Weekly MonthlyPensionsHow much?How often?Name (first, middle, last & suffix): Weekly Monthly Every two weeks Yearly Twice a month Other Weekly Monthly Every two weeks Yearly Twice a month Other Every two weeks Yearly Twice a month OtherRetirement accountsName (first, middle, last & suffix):Section 8 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 .7

8Tell us about other income (continued) Cross out any information that is not correct about members of your household. Write in any new information.Alimony receivedHow much?How often?Name (first, middle, last & suffix): Weekly MonthlyFarming or fishing (profit after business expenses)How much?How often?Name (first, middle, last & suffix): Weekly MonthlyRental income or royalties (profit after business expenses)How much?How often?Name (first, middle, last & suffix): Weekly MonthlyOther income Type:How much?How often?Name (first, middle, last & suffix): Weekly MonthlyOther income Type:How much?How often?Name (first, middle, last & suffix): Weekly Monthly Every two weeks Yearly Twice a month Other Every two weeks Yearly Twice a month Other Every two weeks Yearly Twice a month Other Every two weeks Yearly Twice a month Other Every two weeks Yearly Twice a month Other If anyone in your household has deductions, tell us what kind.Alimony paid to someone elseHow much?How often?Name (first, middle, last & suffix): Weekly MonthlyStudent loan interest paidHow much?How often?Name (first, middle, last & suffix): Weekly MonthlyOther deductionsHow much?How often?Name (first, middle, last & suffix): Weekly Monthly Every two weeks Yearly Twice a month Other Every two weeks Yearly Twice a month Other Every two weeks Yearly Twice a month Other List the names of anyone whose income changes from month to month. Also tell us how much you thinktheir 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: 2.Name (first, middle, last & suffix):What do you expect his or her income to be this year? Amount: 3. Check here if you do not know what the income will be this year. Check here if you do not know what the income will be this year.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

9Read and sign this applicationRenewal 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 incomeinformation 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 makechanges 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 Iam signing this renewal form under penalty of perjury.That means that I have provided true answers to allthe questions on this form to the best of my knowledge,and I know that I may be subject to penalties underfederal law if I provide false or untrue information. Iknow that I must tell [state agency] if anything changesand is different from what I wrote on this form. I cancall XXX-XXX-XXXX or visit [web address] to report anychanges. I understand that a change in my informationmight affect whether someone in my householdqualifies for coverage. Iknow that under federal law, discrimination is notpermitted on the basis of race, color, national origin,sex, age, sexual orientation, gender identity, or disability.I can file a complaint of discrimination by visitinghhs.gov/ocr/office/file. IfI think [state agency] has made a mistake, I can appealits decision. To appeal means to tell someone at [stateagency] that I think the action is wrong, and ask for afair review of the action. I know that I can find out howto appeal by contacting [state agency] at XXX-XXX-XXXX.Someone from [state agency] will explain anything aboutthis application to me if I need that. Iunderstand that if I do not qualify for Medicaid, [stateagency] will check to see if I qualify for other kinds of healthcoverage. [State agency] may send my information toanother program so they can see if I qualify. [State agency]will check my answers using information from computer datasources, including the Internal Revenue Service (IRS), theSocial Security Administration, the Department of HomelandSecurity and others. If the information does not match,[state agency] may ask me to send more information. Iunderstand that, after my death, [state agency] can file aclaim against my estate to recover money that the state paidfor coverage provided to me. This process must happenif I am in a medical institution and not expected to returnhome, or if I am 55 years of age or older and the state paysfor my nursing facility services, home and community basedservices, or related hospital and prescription drug services.The amount recovered by the [state agency] will not bemore than the amount Medicaid paid for my care. Iunderstand that when I send in this form, it means I havepermission from everyone whose information is on the formto submit their information to [state agency] and receive anycommunications about their eligibility and enrollment. Iunderstand that [state agency] is authorized to collectinformation on this form, and other supporting informationincluding Social Security numbers, under the PatientProtection and Affordable Care Act (Public Law No. 111-148),as amended by the Health Care Education Reconciliation Actof 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 authorizedrepresentative 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: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

Attachment APeople applying for Medicaid for the first timeFor people listed in Section 4, Page 4Tell us about anyone in your household who wants to apply for Medicaid. Do not answer these questions for peoplewho 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 citizenshipIs this person a U.S. citizen or U.S. national? Yes NoIf yes, go to "Tell us more information about this person"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 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 about race and ethnicity. You may choose not to answer these questions.If this person is Hispanic/Latino,check all that apply:What is this person’s race? Check all that apply: White Mexican Mexican American Black or AfricanAmericanChicano/aPuertoRican AmericanIndian or Cuban OtherAlaska NativeName of person applying: Asian Indian Chinese Filipino Japanese Korean Vietnamese Other Asian Native Hawaiian Guamanian or Chamorro Samoan Other Pacific Islander OtherName (first, middle, last & suffix) Tell us about citizenshipIs this person a U.S. citizen or U.S. national? Yes NoIf yes, go to "Tell us more information about this person"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 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 about race and ethnicity. You may choose not to answer these questions.If this person is Hispanic/Latino,check all that apply:What is this person’s race? Check all that apply: White Mexican Mexican American Black or AfricanAmerican Chicano/a Puerto RicanAmericanIndian or Cuban Other 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 BAmerican Indian or Alaska Native familymember (AI/AN) To help you fill out Section 6, page 5Tell 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 urbanIndian 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 NoIf no, does this person qualify to get these services? Yes NoList any income that includes money from these sources: Payments Paymentsfrom natural resources, farming, ranching, fishing, leases, or royalties fromland designated as Indian trust land by the Department of Interior (including reservations andformer reservations) Money2.How much income? from a tribe for natural resources, usage rights, leases, or royaltiesfrom selling things that have cultural significanceHow often? Weekly Every two weeks Monthly Twice a month YearlyName (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 NoIf no, does this person qualify to get these services? Yes NoList any income that includes money from these sources: Payments Paymentsfrom natural resources, farming, ranching, fishing, leases, or royalties fromland designated as Indian trust land by the Department of Interior (including reservations andformer reservations) Money?How much income? from a tribe for natural resources, usage rights, leases, or royaltiesfrom selling things that have cultural significanceHow often? Weekly Every two weeks Monthly Twice a month YearlyQuestions? 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 .11

Attachment CAssistance with completing this applicationAn authorized representative is a trusted friend, partner, or lawyer you choose to sign yourrenewal form, get information about this renewal form, and act for you with this agency. If you have an authorized representative now, please answer these questions.We show that you chose this person as your authoriz

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 pers