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The Florida DH 3212 form serves as a crucial tool for individuals seeking extended family planning benefits under the Medicaid Family Planning Waiver program. This application is designed to gather essential information about the applicant’s personal details, reproductive history, and financial situation. It includes sections for contact information, such as residence and mailing addresses, as well as inquiries about previous family planning services like hysterectomies or tubal ligations. Applicants must also indicate their desire to receive family planning services and provide details about all household members, including their income sources and health insurance status. Importantly, the form requires proof of U.S. citizenship and identity, as well as consent for the Department of Health to access relevant financial and medical information. Understanding the eligibility criteria is vital; applicants must have lost full Medicaid coverage, not undergone certain reproductive procedures, and meet specific income guidelines. Completing the DH 3212 form accurately and thoroughly is essential for a timely determination of eligibility, ensuring that individuals can access the necessary family planning services they seek.

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Office Date Received

 

 

 

Health Insurance Application for Extended Family Planning Benefits

 

 

 

 

 

 

 

A Special Medicaid Program

 

 

 

 

 

 

 

 

 

 

 

 

 

Name:

First

M.I.

Last

Maiden Name

 

Area Code

Phone Number

 

 

 

 

 

 

 

(

)

 

 

Residence:

Number

Street

Apt. No.

City

County

 

State

Zip Code

 

 

 

 

 

Mailing Address (Required if different from above):

 

 

 

If no home phone, number where you can be

 

 

 

 

 

 

 

reached

 

(

)

Please answer the following questions:

 

 

 

 

 

 

 

 

1.

In the past, have you had one or both of the following services?

Hysterectomy: Yes

No Tubal ligation: Yes No

 

 

 

 

 

2.

What was the date of your last menstrual period? __________________ Yes No

 

 

 

 

 

 

3.

The benefits you will receive are intended to delay pregnancy through family planning services. Do you wish to receive these services? Yes No

 

 

 

4.List all of the people who live in your home (write your name first):

**Only the applicant must provide her Social Security Number and her proof of citizenship and identity.

First

M.I.

Last

 

Relationship to

 

**Social Security

 

Date of Birth

Race

Sex

US Citizen?

** If no, give INS

Date of

Applied for

 

 

 

 

 

 

Applicant

 

 

Number

 

 

 

 

 

Yes

No

ID Number

Entry

Medicaid?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

(Self)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5. Income: Complete the following information on anyone in the home who gets money from any source (include your parents if you are under age 21 and live with them):

 

 

 

Name of Person

 

Income Source

 

 

Gross Income

 

How Often Are You Paid This Amount?

 

Additional Information

 

 

Receiving Income

 

 

 

 

 

(Before Deduction)

 

 

(weekly, biweekly, monthly)

 

 

 

 

 

 

 

 

 

Current Job: Employer’s Name

 

 

 

 

 

 

 

 

Employer’s Address/Phone Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current Job: Employer’s Name

 

 

 

 

 

 

 

 

Employer’s Address/Phone Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Child Support

 

 

 

 

 

 

 

 

 

 

 

Child Care Cost for Job:

 

 

 

 

 

Contributions from Others

 

 

 

 

 

 

 

 

 

 

Paid by:

 

 

 

 

 

 

 

Unemployment Benefits

 

 

 

 

 

 

 

 

 

 

 

Paid to:

 

 

 

 

 

 

 

Social Security/SSI

 

 

 

 

 

 

 

 

 

 

 

Child(ren) paid for:

 

 

 

 

 

 

 

Other Income – List Type

 

 

 

 

 

 

 

 

 

 

 

Amt. Paid: $

How often:

6. Do you have health insurance? Yes No If yes, give the name of the insurance company: _________________________________

 

 

 

 

7.

If you are 18 or under, are you enrolled in any KidCare program? Yes No

 

 

 

 

 

 

 

 

 

 

 

 

8.

If yes, does your insurance have family planning as a benefit?

Yes No

 

 

 

 

 

 

 

 

 

 

 

 

9.Please attach proof of US citizenship and identity to this application. Evidence of U.S. citizenship includes but is not limited to: a U.S. Passport, a U.S. Birth Certificate, Form FS-240, Report of Birth Abroad of a Citizen of the U.S. or Form FS 545 or From DS1350, Certification of Birth Abroad. Only originals or certified copies are acceptable.

CERTIFICATION AND AUTHORIZATION: I certify that the information provided on this application is true and correct to the best of my knowledge. By signing this form, I give consent to the Department of Health to obtain and to release my confidential financial and medical information for the purpose of determining eligibility for the Family Planning Waiver Program. I therefore authorize the following programs under Medicaid, MomCare, WIC, and DCF or their agents to contact me or my healthcare provider(s) for the purpose of coordination of care, payment of claims for services, quality improvement of services concerning my participation in the family planning waiver program. My authorization to release information includes any medical, mental health, alcohol/drug abuse, sexually transmitted disease, tuberculosis, HIV/AIDS, and adult or child abuse information. I understand that the information I have provided shall be kept confidential in accordance with Florida and federal laws. I have read and understand my rights and responsibilities as they apply to the family planning waiver program and that authorization shall remain in effect unless withdrawn in writing.

Signature of Applicant:

 

Date:

 

Eligibility Staff Signature/Date:

 

FMMIS Termination Date:

 

 

 

 

 

 

Mail or bring this application and any letter you received to your local county health department (see attached list). DO NOT SEND THIS APPLICATION TO MEDICAID.

DH 3212, 11/06 Stock No. 5744-000-3212-0

Florida Department of Health Instructions for Completing the

Health Insurance Application for Extended Family Planning Benefits

(Medicaid Family Planning waiver)

The information on the application is needed to help determine if you are approved for the Medicaid Family Planning Waiver program. You are eligible for this program if you have:

Lost your full Medicaid

Have not had a hysterectomy or tubal ligation.

Not pregnant.

Desires family planning services.

Income is less than or equal to 185% current federal poverty level.

In order to assist with this determination we need you to complete the application, answer the questions (1-9) and sign and date the form. Failure to complete the application will delay the determination for benefits as well as your duration or time on this program, if eligible. You must sign and date the form after the date that you lost your full Medicaid.

Fill in the rows starting with Name, Residence and Mailing Address. Please print your information. Please complete or fill in the information requested in these rows on the form. Please include your mailing address if different from your residence (home) address. This contact information is important. You will be contacted by phone if additional information is needed; you will be contacted by mail to let you know about your eligibility for the program.

Questions 1-3 ask for your reproductive history and whether you desire to participate in the Family Planning Waiver program. Please answer questions 1 through 3.

Question 4 asks for a list of all of the people who live with you or live in your home. Please complete the information requested of yourself as well as the other people or persons that live with you or in your home. Please note that only you, the applicant will need to provide your:

social security number

certified proof of your citizenship and identity, if claiming to be a U.S. Citizen and

proof of your income, pay stubs from the last four weeks, if employed.

Question number 5 asks for the name, income sources, and relationship for not only yourself but the people living with you or in your home. Please complete the information requested of yourself as well as the other people or persons that live with you or in your home including current job, employer’s address and phone number.

Please fill out the column with the heading Child Care Cost for Job.

Questions 6-8 ask for insurance information. Please answer questions 6-8

Read the Certification and Authorization section and sign and date the form. You need to mail or bring this application to your local health department.

DH 3212

➤ PDF File

Form Specifications

Fact Name Details
Form Purpose The DH 3212 form is used to apply for extended family planning benefits under Florida's Medicaid program.
Eligibility Criteria Applicants must not be pregnant, have lost full Medicaid, and desire family planning services. Income must be at or below 185% of the federal poverty level.
Required Information Applicants must provide personal details, including name, address, and contact information. They must also disclose their reproductive history and household income.
Social Security Number Only the applicant is required to provide their Social Security Number and proof of citizenship.
Health Insurance Disclosure Applicants must indicate if they have health insurance and whether it covers family planning services.
Submission Guidelines The completed form should be mailed or delivered to the local county health department. It should not be sent directly to Medicaid.
Confidentiality Assurance Information provided is confidential and protected under Florida and federal laws.
Certification Requirement Applicants must sign the form, certifying that the information is accurate and authorize the release of medical and financial information.
Governing Laws The DH 3212 form is governed by Florida Statutes Chapter 409, which outlines Medicaid eligibility and benefits.

Florida Dh 3212: Usage Guidelines

After completing the Florida DH 3212 form, the next step involves submitting it to your local county health department. Make sure to include any required documentation, such as proof of U.S. citizenship and identity, to avoid delays in processing your application.

  1. Begin by filling in the Name section with your first name, middle initial, last name, and maiden name if applicable.
  2. Provide your Phone Number and Residence address, including the street number, apartment number, city, county, state, and zip code.
  3. If your mailing address differs from your residence, include that information in the Mailing Address section.
  4. If you do not have a home phone, provide a number where you can be reached.
  5. Answer the questions regarding your reproductive history in Questions 1-3 by checking the appropriate boxes.
  6. In Question 4, list all individuals living in your home, starting with your name. Provide their relationship to you, Social Security Number, date of birth, race, sex, and citizenship status.
  7. Complete Question 5 by detailing the income sources and gross income for each person listed, including how often they are paid.
  8. Answer Questions 6-8 regarding health insurance and KidCare program enrollment.
  9. Attach proof of U.S. citizenship and identity as specified in the instructions.
  10. Read the Certification and Authorization section carefully. Sign and date the form at the bottom.
  11. Finally, mail or deliver the completed application and any accompanying letters to your local county health department.

Your Questions, Answered

What is the Florida DH 3212 form?

The Florida DH 3212 form is an application for the Health Insurance Application for Extended Family Planning Benefits. This form is used to apply for a special Medicaid program that provides family planning services to eligible individuals. It helps determine if someone qualifies for the Medicaid Family Planning Waiver program.

Who can apply using the DH 3212 form?

What information do I need to provide on the form?

You will need to provide personal information such as your name, contact details, and social security number. The form also requires information about your reproductive history, household members, and their income sources. Additionally, you must indicate if you have health insurance and if you are enrolled in any KidCare programs.

How do I submit the DH 3212 form?

After completing the form, you must mail or bring it to your local county health department. It is important not to send the application directly to Medicaid. Ensure that you include any required documents, such as proof of U.S. citizenship and identity, with your application.

What happens after I submit the form?

Once you submit the DH 3212 form, the health department will review your application to determine your eligibility for the Family Planning Waiver program. You may be contacted by phone or mail if additional information is needed. You will also receive a notification regarding your eligibility status.

What should I do if I need help completing the form?

If you need assistance with the DH 3212 form, you can reach out to your local county health department for guidance. They can help clarify any questions you have about the application process or the information required.

Common mistakes

  1. Incomplete Personal Information: Failing to provide complete personal details such as your full name, residence, and mailing address can lead to processing delays. Ensure that all sections are filled out accurately.

  2. Missing Social Security Number: Only the applicant needs to provide a Social Security number. Omitting this crucial piece of information will hinder the application process.

  3. Neglecting to List All Household Members: When asked to list all individuals living in your home, ensure that you include everyone. This includes providing their relationship to you and their income details if applicable.

  4. Incorrect Income Reporting: Be precise when reporting income sources and amounts. Inaccuracies can affect eligibility for the program.

  5. Forgetting to Attach Proof of Citizenship: The application requires proof of U.S. citizenship and identity. Failing to include this documentation can result in immediate denial.

  6. Not Answering All Questions: Ensure that you answer all questions, particularly those regarding reproductive history and insurance coverage. Incomplete answers can delay processing.

  7. Ignoring the Signature Requirement: Do not forget to sign and date the application. An unsigned form will not be processed.

  8. Submitting Without Reviewing: Always review the completed form for accuracy before submission. Mistakes may lead to delays or denials.

  9. Failing to Submit to the Correct Location: Ensure that you submit the application to your local county health department. Sending it elsewhere can cause significant delays.

Documents used along the form

The Florida DH 3212 form is an essential document for individuals applying for extended family planning benefits through Medicaid. To support this application process, several other forms and documents may also be required. Each of these documents plays a crucial role in verifying eligibility and ensuring that applicants receive the appropriate assistance. Below is a list of commonly used forms and documents that accompany the DH 3212.

  • Proof of U.S. Citizenship: This document verifies the applicant's citizenship status. Acceptable forms include a U.S. passport, birth certificate, or other official documents that confirm citizenship.
  • Social Security Card: The applicant must provide their Social Security number for identification purposes. A physical card or an official document showing the number is necessary.
  • Income Verification Documents: These may include recent pay stubs, tax returns, or bank statements. They help establish the applicant's financial situation and eligibility for benefits.
  • Health Insurance Information: If the applicant has health insurance, they need to provide details about their policy. This includes the name of the insurance company and the type of coverage available.
  • Proof of Residency: Documents such as utility bills, lease agreements, or government correspondence can confirm the applicant's current residence, which is vital for eligibility.
  • Family Size Documentation: This may include birth certificates or legal documents for all individuals living in the household. This information is necessary to assess the overall family income and eligibility.
  • KidCare Enrollment Confirmation: If applicable, proof of enrollment in any KidCare program is required. This ensures that the applicant is receiving all available benefits.
  • Authorization for Release of Information: This form allows the Department of Health to access necessary medical and financial information. It is crucial for processing the application and determining eligibility.
  • Application for Medicaid: If the applicant is not currently enrolled in Medicaid, they may need to complete a separate Medicaid application to determine eligibility for other assistance programs.

Gathering these documents can streamline the application process for extended family planning benefits. Each piece of information helps to create a complete picture of the applicant's situation, ensuring that they receive the support they need. Understanding the requirements and preparing the necessary documentation in advance can make a significant difference in the overall experience.

Similar forms

The Florida DH 3212 form is primarily used for applying for extended family planning benefits under Medicaid. There are several other documents that serve similar purposes in terms of gathering personal information, determining eligibility for health-related services, or applying for benefits. Here are eight documents that share similarities with the Florida DH 3212 form:

  • Medicaid Application Form: This form collects personal and financial information to determine eligibility for Medicaid services, similar to the DH 3212's focus on family planning benefits.
  • Food Assistance Application: Like the DH 3212, this document assesses household income and composition to determine eligibility for food assistance programs.
  • Temporary Cash Assistance Application: This application gathers information about income and family dynamics to evaluate eligibility for temporary financial aid, akin to the DH 3212's purpose of assessing family planning needs.
  • Health Insurance Marketplace Application: This form allows individuals to apply for health insurance and requires similar demographic and income information as the DH 3212.
  • KidCare Application: This document is used to apply for health insurance for children and requires similar information about family income and household members, much like the DH 3212.
  • WIC Application: The Women, Infants, and Children (WIC) program application collects data on family income and nutritional needs, paralleling the DH 3212's focus on family planning services.
  • Medically Needy Program Application: This application assesses financial need and medical expenses to determine eligibility for additional Medicaid services, similar to the evaluation process in the DH 3212.
  • Supplemental Security Income (SSI) Application: This form gathers financial and personal information to assess eligibility for SSI benefits, reflecting the information-gathering nature of the DH 3212.

Each of these documents plays a crucial role in the broader context of health and financial assistance, ensuring that individuals and families receive the support they need based on their specific circumstances.

Dos and Don'ts

When filling out the Florida DH 3212 form, attention to detail is crucial. Here are some important do's and don'ts to keep in mind:

  • Do ensure that all personal information is accurate, including your name, address, and contact details.
  • Don't skip any questions. Each section is important for determining eligibility.
  • Do provide your Social Security Number and proof of citizenship as required.
  • Don't submit the application without your signature and date. This is essential for processing.
  • Do include information about all household members, as this affects income eligibility.
  • Don't forget to attach the necessary documentation, such as proof of income and citizenship.
  • Do read the Certification and Authorization section carefully before signing.
  • Don't send the application to Medicaid; deliver it to your local county health department instead.
  • Do keep a copy of the completed form for your records.

Following these guidelines can help ensure a smoother application process and improve your chances of receiving the benefits you need.

Misconceptions

Understanding the Florida DH 3212 form can be challenging, especially with the various misconceptions that often arise. Here are six common misunderstandings, along with clarifications to help you navigate the application process more effectively.

  • Misconception 1: Only low-income individuals can apply for the DH 3212 form.

    • While income is a significant factor, the form is designed for those who have lost full Medicaid benefits, regardless of their current financial situation, as long as they meet the eligibility criteria.

  • Misconception 2: Completing the form is optional if I have health insurance.

    • This is not true. If you wish to access family planning services through the Medicaid Family Planning Waiver program, you must complete the DH 3212 form, even if you have health insurance.

  • Misconception 3: I need to provide proof of citizenship for everyone in my household.

    • Only the applicant needs to provide proof of citizenship and identity. Other household members do not need to submit this documentation.

  • Misconception 4: The form can be submitted online.

    • The DH 3212 form must be mailed or delivered in person to your local county health department. Online submissions are not accepted.

  • Misconception 5: If I had a hysterectomy or tubal ligation, I cannot apply.

    • This is incorrect. Individuals who have had these procedures may still be eligible for the program, provided they meet other criteria.

  • Misconception 6: I can leave questions blank if they do not apply to me.

    • Leaving questions unanswered can delay the processing of your application. It is best to answer all questions to the best of your ability, even if that means marking "No" or "Not Applicable."

By addressing these misconceptions, applicants can approach the Florida DH 3212 form with greater confidence and clarity, ensuring a smoother experience in seeking family planning benefits.

Key takeaways

Filling out the Florida DH 3212 form can seem daunting, but understanding its key components can make the process smoother. Here are some important takeaways to keep in mind:

  • Purpose of the Form: The DH 3212 form is used to apply for the Medicaid Family Planning Waiver program, which provides health insurance for family planning services.
  • Eligibility Criteria: To qualify, applicants must not be pregnant, should not have had a hysterectomy or tubal ligation, and their income must be at or below 185% of the federal poverty level.
  • Complete Personal Information: Ensure that your name, address, and contact information are filled out accurately. This is crucial for communication regarding your application.
  • Reproductive History: Be prepared to answer questions about your reproductive health, including any past surgeries and your desire to receive family planning services.
  • Income Disclosure: You must provide detailed information about your income and that of anyone living in your household. This includes pay stubs and sources of income.
  • Proof of Citizenship: Only the applicant needs to submit proof of citizenship and identity. Acceptable documents include a U.S. passport or birth certificate, and these must be original or certified copies.
  • Submission Process: Once completed, the application should be mailed or delivered to your local county health department. Do not send it to Medicaid directly.

By keeping these points in mind, you can navigate the application process with confidence. Make sure to double-check your answers and gather all necessary documents before submitting the form.