BUY-IN APPLICATION
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YOUR RIGHTS AND RESPONSIBILITIES: Read this sheet before you sign your name.
YOU HAVE THE RIGHT TO:
•Apply for assistance and have a determination of your eligibility made without regard to race, color, sex, age, handicap, religion, national origin, marital status or political belief.
•Have a representative help you fill out the eligibility forms.
•Have action taken on your application promptly and be notified of such action.
•Be informed of other available services of the Department of Children and Families.
•Request a fair hearing when you disagree with a decision of the Department of Children and Families.
•Have the information about you and/or your spouse that is collected by the department treated confidentially in accordance with federal and state laws.
YOU HAVE THE RESPONSIBILITY TO (things you must do):
•Assist in determining your eligibility by giving complete and correct information and provide written proof of information, as requested, within the time limits given.
•Declare the citizenship or alien status for you and your spouse by signing the Medicaid/Medicare Buy-In Application.
•File for any payments or benefits from other sources if this application, or other information, indicates that you or your spouse may be eligible for such payments or benefits.
•Assign your rights to third party benefits and cooperate in reporting any insurance or other health plan that covers medical costs for you (and/or your spouse, if applying) unless good cause can be shown not to do so.
•Report changes in your situation (e.g., income, assets) within 10 days of the change.
•Report your (and your spouse’s, if applying) Social Security numbers. Without accurate numbers, we will be unable to provide Medicaid/Medicare buy-in benefits if you are determined eligible for any benefits.
IMPORTANT INFORMATION ABOUT MEDICAID:
Any person (including the designated representative) who knowingly withholds information or knowingly misrepresents the truth may be punished under federal or state law or both. If you get medical assistance for which you do not qualify, you may have to repay the cash value of that assistance.
Certification of Citizenship/Alien Status: I certify, under the penalty of perjury, by signing my name on this application, that I and my spouse (if applicable) are U.S. citizens or nationals of the United States or qualified aliens.
Certification: In signing this application, I swear and affirm, under penalty of perjury, that the information I have given on this application is correct and complete to the best of my knowledge. I have read and understand the above rights and responsibilities and important information about Medicaid.
Applicant |
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Representative Signature: |
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HELPING PERSON: (Official use only) |
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Signature of Individual Who Assisted Applicant in Completing Buy-In Application Form
In accordance with Federal law and our policy, the Department of Children and Families is prohibited from discriminating on the basis of race, color, national origin, sex, age, disability, religion, political belief, or marital status.