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The Georgia Application for Medicaid is a crucial document designed for individuals seeking assistance with healthcare costs. This form not only facilitates access to Medicaid but also includes provisions for Medicare Savings for qualified beneficiaries. Completing this application accurately is essential for determining eligibility and ensuring that applicants receive the support they need.

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Blank Georgia Application For Medicaid PDF Form

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The Georgia Application for Medicaid is a vital resource for individuals seeking assistance with healthcare coverage. This form not only facilitates access to Medicaid benefits but also includes provisions for Medicare Savings programs designed for qualified beneficiaries. When filling out the application, it is crucial to read each section carefully and provide accurate responses. The form requires personal information, including the applicant's name, address, and details about any dependents. Additionally, applicants must disclose their living arrangements, health insurance status, and any existing resources or income. It is important to note that a telephone interview may be necessary to process the application, and the Department of Family and Children Services (DFCS) will conduct a thorough review to determine eligibility. Furthermore, applicants must sign the form, indicating their understanding of the rights and responsibilities associated with receiving assistance. This comprehensive application serves as a gateway to essential healthcare services, ensuring that individuals receive the support they need during challenging times.

Georgia Application for Medicaid & Medicare Savings for Qualified Beneficiaries

(QMB - payment of premiums, coinsurance, and deductibles;

SLMB - payment of Part B premium; and QI-1 - payment of Part B premium)

INSTRUCTIONS:

1. Read the application carefully & answer each question accurately. Attach additional pages if needed.

2. Sign and mail application to: __________________________ County DFCS

(Mail or deliver application to the DFCS office in your county of residence)

______________________________________

ATTN: ________________________________

3.A telephone interview may be required for these programs. Be sure to enter phone # below.

4.The DFCS Medicaid Specialist will review this application. If it appears that you may be eligible for full Medicaid coverage, the Medicaid Specialist will contact you for more information and verifications.

PERSONAL INFORMATION: You may have someone help you complete this application.

Applicant’s Name (Last, First, Middle Initial)				If you wish to name a person to act on your behalf,
				complete the information below:
				Name (Last, First, Middle Initial)
Mailing Address				Name (Last, First, Middle Initial)
Mailing Address

Street Address				Mailing Address

City	State	Zip		City	State	Zip
Do you own/are you purchasing home?		□ Y	□ N
Phone	County			Phone
E-Mail Address				E-Mail Address
Nursing Facility (if applicable)				Relationship to Individual

COMPLETE THIS INFORMATION FOR YOU AND YOUR SPOUSE.

Name (Self):	Birthdate	Sex	Race	U.S. Citizen	Social Security	Marital
				(Yes or No)	Number	Status
Maiden/other name(s):

Name (Spouse):
Maiden/other name(s):

Are you applying for your spouse, too? □ Yes		□ No
Are you blind or disabled? □ Yes	□ No - Is your spouse blind or disabled? □ Yes □ No

LIVING ARRANGEMENT: Check the box(es) that best describes your current situation.

Living In	Nursing	Another’s	Hospice	Hospital	Katie	Community	Assisted	Other/
Own Home	Facility	Home			Beckett	Care	Living	Renting
	Date			Date		Date
	Admitted:			Admitted:		Admitted:

DHR 700 (R. 05/11)

HEALTH INSURANCE:

Do you have Medicare?		Type of Coverage		Effective Date:	Have you ever
□ Yes	□ No	□ Part A	□ Part B	______________	received SSI?
Are you enrolled in a Medicare		(hospital)	(doctor)		□ Yes	□ No
HMO or Medicare Drug program?		⁭ Part D		Medicare Number:	If so, when did it
□ Yes	□ No	(RX)		____________	end?________


Does your spouse have		Type of Coverage		Effective Date:	Has your spouse
Medicare?	□ No	□ Part A	□ Part B	______________	ever received SSI?
□ Yes		⁭ Part D		Medicare Number:	□ Yes	□ No
					If so, when did it
				____________	end?________

Do you have other health insurance?	□ Yes	□ No
Does your spouse have other health insurance?	□ Yes	□ No

If you answered yes to either of these questions, please complete the following information:

	Health Insurance	Type of Coverage	Effective	Policy
	Company Name,	(Hospital, Medicare	Date	Number
	Address, and Telephone	Supplement, Drugs, Major
	Number	Medical,)
Self

Spouse

Attach copies (front and back) of Medicare and insurance cards if applicable.

REAL PROPERTY: Do you own all or part of any real estate in which you do not live?□ Yes □ No If yes, please complete the following for each piece of real estate. Do not list the house or mobile home in which you live.

Address	Value	Amount Owed

Do you or your spouse own a car, truck, boat, camper, utility trailer, recreational vehicle, etc.?

DHR 700 (R. 05/11)

RESOURCES: Check all resources (assets) owned by you, your spouse, or jointly owned with someone else. Include any accounts or properties on which your name(s) appear. Attach additional pages if necessary.

Do you or your spouse have any of the following resources?

Checking account	□ Yes	□ No	Funeral plans/ prepaid burial item	□ Yes	□ No
Savings account	□ Yes	□ No	Burial plots or contracts	□ Yes	□ No
Government bonds	□ Yes	□ No	Stocks and bonds	□ Yes	□ No
Trust funds	□ Yes	□ No	Other (IRA, CD, promissory note, etc.)	□ Yes	□ No
Have you or your spouse given away any assets for less than its value?				□ Yes	□ No

If you answered yes to any of these questions, describe below. Attach additional pages if necessary.

Type of Resource		Account/ Policy	Value	Name of Bank, Insurance Company,
		Number		Etc.



Do you or your spouse have a life insurance policy?					□ Yes	□ No
If yes, please complete the following information. Attach additional pages if necessary.
Policy Owner	Insurance Company		Policy Number		Face	Cash Value
					Value

INCOME AND EARNINGS: List all types of earnings and income that you and your spouse receives. List the income amount before deductions (such as taxes, insurance, or Medicare premiums) are taken out. Attach additional pages if needed. Income includes, but is not limited to:

Social Security		SSI	Wages/ Self-Employment
Railroad Retirement Benefits		Veterans’ Benefits	Trust or Annuity Payments
Pensions/ Retirement Benefits		Rental Income Paid to You	Oil Royalties/ Mineral Rights
Name of	Type of	Source of Income or Amount	How Often	Claim Number
Person Who	Income	Name of Employer	Received?	(if applicable)
Receives			(weekly,
Income			monthly, etc.)
Income

Are you a veteran? □ Yes □ No Is your spouse a veteran? ⁭ Yes ⁭ No

Where did you and spouse work in the past? ____________________________________________________

Do you or your spouse have any unpaid medical bills ?

□ Yes □ No

DHR 700 (R. 05/11)

PRIVACY STATEMENT:

Federal and state laws and regulations limit the use and disclosure of confidential information concerning applicants and recipients of all agency programs to purposes directly related to the administration of these programs.

ASSIGNMENT OF RIGHTS OF PAYMENT FOR MEDICAL SUPPORT AND OTHER MEDICAL CARE:

(If you are applying on behalf of another individual and do not have the power to execute an assignment for that individual, the individual will need to execute an assignment of the rights described below, as a condition of his or her eligibility for the benefits covered by this application.) As a condition of my eligibility, I agree to assign to the

State all rights to medical support and to payment for medical care from any third party (hospital and medical benefits). I agree to cooperate with the state in identifying and providing information to assist the state in pursuing any third party who may be liable to pay for care and services. I understand that I must report any payments received for medical care within ten days.

APPLICANT’S STATEMENT OF UNDERSTANDING AND AGREEMENT:

I understand that, by signing this application, I am agreeing to a full investigation or review of my eligibility by state and/or federal officials. This may include inquiries of employers, medical providers, financial institutions, and other business and professional persons and review of any agency records. I also agree that my application authorizes these agencies to release to this agency the information needed to determine my eligibility. I agree to provide the documents necessary to establish eligibility. If documents are not available, I agree to give the name of the person or organization from which this agency may obtain the necessary proof.

I understand that each individual who receives assistance must provide or apply for a Social Security Number. I authorize the use of my (our) Social Security Number for such purposes as identification, program reviews or audits, and computer matching with other agencies and institutions such as banks, saving and loan associations, and other government agencies, including Internal Revenue Service, to verify eligibility for assistance.

I understand that my application will be considered without regard to race, color, sex, age, handicap, religion, national origin, or political belief. I understand that I may request a fair hearing if I disagree with an agency decision in my case and that I may be represented by any person I choose.

I understand that Medicaid members who, are an inpatient in a nursing facility, intermediate care facility for

the mentally retarded, or other mental institution that have their medical care paid by Medicaid will be subject to the Medicaid Estate Recovery Program. Additionally, Medicaid members who are 55 years of age or older and who receive home and community based services or are enrolled in and receive services through a waiver program are also subject to Estate Recovery. I acknowledge receipt of a written notice that medical assistance payments made on my behalf may be recovered from my estate after my death.

I certify that I (or if filing for my spouse, my spouse and I) am a U.S. citizen, national, or alien in qualified alien status. If this application is being filed on behalf of another individual or individuals, the actual applicant(s) will need to make this certification.

APPLICANT(S) OR REPRESENTATIVE MUST READ AND SIGN:

State and federal law provide for fine, imprisonment, or both for any person who withholds or gives false information to obtain assistance to which he is not entitled. I understand the questions on this application and I certify, under penalty of perjury, that the information given by me on this form is correct and complete to the best of my knowledge. I agree to notify this agency of changes in my income, resources, or living arrangements, which might affect my right to receive assistance.

Signature of Applicant or Representative:

Date:

Signature of Applicant’s Spouse or Representative:

Date:

DHR 700 (R. 05/11)

DECLARATION OF CITIZENSHIP/IMMIGRATION STATUS

Georgia Department of Human Services

Division of Family and Children Services

I understand that the Georgia Division of Family and Children Services (DFCS) may require verification from the United States Department of Homeland Security (DHS) of my/my children’s citizenship or immigration status when seeking benefits. Information received from DHS may affect my/my children’s eligibility.

Please fill out and sign ONE or BOTH of the following statements as it pertains to the status of each person seeking benefits.

CHILDREN SEEKING BENEFITS

		U.S.	Lawfully	Date Naturalized
		Citizen	Admitted	or Admitted into U.S.
			Immigrant
Name	Place of Birth(city,state,country)	(check whichever applies)		(If applicable)

I, ________________________ attest to the identity of the child/children listed above and

(PRINT NAME)

certify under penalty of perjury, that the information written and checked above is true.

____________________________________		________________________
SIGNATURE (PARENT/GUARDIAN)			(DATE)

	ADULT(S) SEEKING BENEFITS
		U.S.		Lawfully	Date Naturalized
		Citizen		Admitted	or Admitted into U.S.
				Immigrant
Name	Place of Birth(city,state,country)	(check whichever applies)			(If applicable)

I, ________________________ certify under penalty of perjury, that the information

(PRINT NAME)

written and checked above is true.
____________________________________	________________________
SIGNATURE (PARENT/GUARDIAN)	(DATE)
______________________________________________________	_____________________________________
SIGNATURE (PARENT/GUARDIAN)	(DATE)

Form 216 (R. 05/11)

➤ PDF File

Fact Name	Fact Description
Form Purpose	This form is used to apply for Medicaid and Medicare Savings Programs in Georgia, specifically for Qualified Beneficiaries.
Governing Laws	The application is governed by federal Medicaid laws and Georgia state regulations under the Department of Human Services.
Eligibility Criteria	Applicants must meet specific income and resource limits to qualify for Medicaid and Medicare Savings Programs.
Submission Process	Applicants should sign and mail the completed application to their local County Department of Family and Children Services (DFCS).
Telephone Interview	A telephone interview may be required to gather additional information or clarify details in the application.
Personal Assistance	Applicants can have someone assist them in completing the application, ensuring all information is accurately provided.
Privacy Statement	Federal and state laws protect the confidentiality of the information provided in the application, limiting its use to program administration.
Asset Reporting	Applicants must report all assets, including real estate and vehicles, as part of the eligibility assessment.
Signature Requirement	By signing the application, the applicant certifies that all information is true and agrees to comply with eligibility requirements.

Filling out the Georgia Application for Medicaid is a crucial step for individuals seeking assistance with medical costs. This process involves providing detailed personal and financial information to determine eligibility. Once the application is completed, it must be submitted to the appropriate county office for review.

Begin by reading the application thoroughly to understand all requirements.
Fill in your personal information, including your name, mailing address, and phone number.
If applicable, provide information about a representative who will act on your behalf.
Indicate whether you own or are purchasing a home, and provide your phone number for a potential telephone interview.
Complete the section for you and your spouse, including names, birthdates, Social Security numbers, and marital status.
Check the appropriate boxes to describe your living arrangement, such as living in a nursing home or community facility.
Provide details about your health insurance coverage, including Medicare and any other health plans.
Disclose any real property you own, excluding your primary residence, and provide details about any vehicles owned.
List all financial resources, including checking and savings accounts, stocks, and bonds.
Detail your income sources, including Social Security, wages, and any other earnings.
Review the privacy statement and assignment of rights section, ensuring you understand the implications of your application.
Sign and date the application, certifying that the information provided is accurate and complete.
Mail or deliver the application to your county’s Department of Family and Children Services (DFCS) office, ensuring that any required attachments are included.

What is the Georgia Application for Medicaid form?

The Georgia Application for Medicaid form is a document that individuals must complete to apply for Medicaid and Medicare Savings programs in Georgia. It collects personal information, financial details, and health insurance coverage to determine eligibility for various assistance programs, including Qualified Medicare Beneficiary (QMB) and Specified Low-Income Medicare Beneficiary (SLMB) programs.

Who is eligible to apply for Medicaid in Georgia?

Eligibility for Medicaid in Georgia generally includes low-income individuals, families, seniors, and people with disabilities. Specific criteria can vary based on the program, but applicants must meet income and resource limits. Additionally, U.S. citizenship or qualified alien status is required.

How do I submit the application?

After completing the application, it should be signed and mailed to your local County Department of Family and Children Services (DFCS) office. It's important to ensure that you include any required documentation and provide a phone number in case a telephone interview is necessary.

What information do I need to provide on the application?

The application requires personal information such as your name, address, and Social Security number. You will also need to disclose details about your household income, resources, health insurance, and living arrangements. This information helps determine your eligibility for Medicaid and related programs.

Is there a need for a telephone interview?

Yes, a telephone interview may be required as part of the application process. If this is necessary, the Medicaid Specialist will reach out to you using the phone number you provided on the application. Be prepared to discuss your application and provide any additional information they may request.

What happens after I submit my application?

Once your application is submitted, a DFCS Medicaid Specialist will review it. If they believe you may qualify for full Medicaid coverage, they will contact you for further information and verification. This process may include checking your financial and medical information.

Can I apply for someone else?

Yes, you can apply on behalf of another individual, such as a spouse or family member. However, you must fill out the application accurately and include their information. The person you are applying for may need to sign a statement to authorize you to act on their behalf.

What if I have other health insurance?

If you or your spouse have other health insurance, you must disclose this on the application. You will need to provide details about the type of coverage, effective dates, and the name of the insurance company. This information is crucial for determining your eligibility for Medicaid benefits.

What should I do if I have questions while filling out the application?

If you have questions while completing the application, you can seek assistance from someone you trust. Additionally, the DFCS office can provide guidance on the application process and answer any specific questions you may have regarding eligibility or required documentation.

Inaccurate Personal Information: Many applicants fail to provide correct personal details, such as names, Social Security numbers, or addresses. This can lead to significant delays in processing the application.
Missing Signatures: Some individuals neglect to sign the application form. Without a signature, the application is incomplete and cannot be processed.
Not Reporting All Income: Applicants often overlook certain sources of income, like rental payments or side jobs. All income must be reported accurately to determine eligibility.
Failure to Attach Required Documentation: Many people forget to include necessary documents, such as proof of income or health insurance cards. This omission can result in the application being denied or delayed.

The Georgia Application for Medicaid is a crucial document for individuals seeking financial assistance for healthcare services. Along with this application, several other forms and documents may be required to support the application process. Below is a list of commonly used documents that applicants should consider when applying for Medicaid in Georgia.

Proof of Identity: This document verifies the applicant's identity and may include a driver's license, state ID, or passport. It is essential for confirming that the applicant is who they claim to be.
Social Security Card: A copy of the applicant's Social Security card is often required. This helps the state verify the individual's Social Security number, which is critical for eligibility assessment.
Income Verification: Documentation such as pay stubs, tax returns, or bank statements that demonstrate the applicant's income level. This information is necessary to determine financial eligibility for Medicaid services.
Asset Documentation: Records of assets owned by the applicant, including bank statements, property deeds, and vehicle titles. This helps assess the applicant's total resources and whether they meet Medicaid's asset limits.
Health Insurance Information: Any existing health insurance cards or policy documents should be included. This information is vital for understanding the applicant's current coverage and potential costs.
Medical Records: Relevant medical documentation may be required, especially if the applicant has ongoing health issues. This can help establish the need for Medicaid services.

Gathering these documents in advance can streamline the application process and help ensure that all necessary information is provided to the Georgia Division of Family and Children Services. Proper preparation can facilitate a smoother review of the application and expedite access to needed healthcare services.

The Georgia Application for Medicaid form shares similarities with several other important documents related to healthcare and assistance programs. Below is a list of these documents and how they relate to the Medicaid application process.

Medicare Application Form: Like the Medicaid application, this form collects personal and financial information to determine eligibility for Medicare, a federal health insurance program primarily for individuals aged 65 and older.
Supplemental Security Income (SSI) Application: This application assesses financial need and eligibility for SSI benefits, similar to how the Medicaid form evaluates income and resources.
Medicaid Renewal Application: This document is used to renew Medicaid benefits and requires updated information on income, resources, and living arrangements, much like the initial application.
Food Stamp Application (SNAP): This application determines eligibility for nutritional assistance and requires similar financial disclosures as the Medicaid application.
Veterans Affairs (VA) Benefits Application: This form assesses eligibility for various VA benefits, including healthcare, requiring personal and financial information akin to the Medicaid application.
Long-Term Care Insurance Application: This document evaluates eligibility for long-term care coverage, often requiring detailed financial information similar to that found in the Medicaid application.
State Health Insurance Assistance Program (SHIP) Application: This application helps seniors navigate Medicare options and may require personal and income information, paralleling the Medicaid process.
Children’s Health Insurance Program (CHIP) Application: This form is used to determine eligibility for health coverage for children, requiring similar financial and household information as the Medicaid application.
Affordable Care Act (ACA) Marketplace Application: This application assesses eligibility for health coverage under the ACA, gathering financial and personal details similar to those requested in the Medicaid application.

Each of these documents plays a crucial role in ensuring that individuals receive the necessary assistance and benefits for their healthcare needs. Understanding the similarities can help streamline the application process and ensure that all required information is accurately provided.

When filling out the Georgia Application for Medicaid form, there are several important steps to follow. Here are six things you should and shouldn't do:

Do read the application carefully and answer each question accurately.
Don't leave any questions blank. If you need more space, attach additional pages.
Do provide your current phone number for any required telephone interviews.
Don't forget to sign the application before mailing it to your local DFCS office.
Do include copies of any relevant documents, like Medicare and insurance cards, if applicable.
Don't provide false information. This could lead to serious consequences.

By following these guidelines, you can help ensure a smoother application process. Remember, it's important to be thorough and honest in your responses.

There are several misconceptions about the Georgia Application for Medicaid form that can lead to confusion. Understanding these can help applicants navigate the process more smoothly.

Misconception 1: The application is only for low-income individuals.

Many believe that only those with extremely low incomes can apply for Medicaid. However, Medicaid also offers coverage for individuals with disabilities and those who meet other specific criteria, regardless of their income level.

Misconception 2: You cannot get help filling out the application.

Some people think they must complete the application alone. In reality, applicants can have someone assist them in filling out the form. This can be a family member, friend, or advocate who understands the process.

Misconception 3: Once you submit the application, you will automatically receive benefits.

Submitting the application does not guarantee benefits. After submission, a Medicaid Specialist will review the application. They may contact the applicant for additional information or verification before making a decision.

Misconception 4: The application process is too complicated to navigate.

While the application may seem overwhelming, it is designed to gather necessary information clearly. Taking it step by step and asking for help when needed can make the process manageable.

□ No If yes, please complete the following information about each vehicle. Attach

additional pages if needed.

Amount Owed

When navigating the Georgia Application for Medicaid, several key points can significantly enhance your experience and understanding of the process. Here are some essential takeaways:

Accuracy is Crucial: Carefully read the application and ensure that all answers are accurate. Incomplete or incorrect information can lead to delays or denials.
Signature Requirement: Don’t forget to sign the application before mailing it to your local Department of Family and Children Services (DFCS) office. This step is essential for processing your application.
Prepare for a Phone Interview: Be ready for a potential telephone interview. Providing your phone number on the application is important, as the Medicaid Specialist may need to reach you for further information.
Documentation is Key: Attach necessary documents, such as proof of income, assets, and health insurance. Missing documents can hinder your application process.
Understand Your Rights: Familiarize yourself with your rights regarding medical support and eligibility. This knowledge empowers you to navigate the system effectively.
Keep Records: Maintain copies of your application and any submitted documents. Having these records can be helpful if you need to follow up or appeal any decisions.

By keeping these points in mind, you can approach the Georgia Medicaid application process with greater confidence and clarity.