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Blank Georgia Medicaid Application PDF Form

The Georgia Medicaid Application form is a crucial document for individuals seeking access to healthcare services under the state's Medicaid program. This form gathers essential information to determine eligibility while ensuring that applicants are treated fairly, without discrimination based on race, color, sex, age, disability, religion, national origin, or political belief. Completing this application accurately is vital, and assistance is available if needed; simply reach out to the Division of Family and Children Services (DFCS) for support.

To begin your journey towards obtaining Medicaid benefits, please fill out the form by clicking the button below.

Blank Georgia Medicaid Application PDF Form

Article Guide

Applying for Medicaid in Georgia involves navigating a comprehensive application form that gathers essential information to determine eligibility for healthcare benefits. This form is designed to be inclusive, ensuring that applicants are not discriminated against based on race, color, sex, age, disability, religion, national origin, or political belief. Key sections of the application include personal details such as name, address, and contact information, along with inquiries about household composition and income. Applicants must indicate if they are applying for themselves or for others, including children and pregnant individuals. Notably, the form allows for the listing of unpaid medical bills and existing health insurance coverage, which can impact eligibility. Furthermore, it addresses specific programs, such as the Chafee Independence Program and Medicaid for pregnant women. The application emphasizes the importance of accuracy and completeness, offering assistance for those who may need help understanding the process. Verification of certain claims, such as pregnancy or income, may be required, and applicants must agree to cooperate with state agencies regarding medical support. Ultimately, this form serves as a critical gateway for individuals and families seeking vital healthcare services in Georgia.

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We will consider this application without regard to race, color, sex, age, disability, religion, national origin or political belief.

Check block(s) that apply to you:

	MEDICAID APPLICATION	FOR COUNTY USE ONLY:
	MEDICAID APPLICATION	Date Received in County Dept
		Date Received in County Dept

Pregnant Woman Families w/Children – LIM

Child(ren) Only – RSM Chafee Independence Program Medicaid

Were you in foster care on your 18th birthday? Yes No In which state?______

PLEASE NOTE: A Face to Face interview is not required for Medicaid applications. Please answer all questions as completely and accurately as possible. If you cannot understand or complete this application, please notify DFCS staff and assistance will be provided free of charge.

Your Name: (Please Print) FIRST

M.I.

Last

Maiden (if applicable)

Today’s Date:

Mailing Address:

City:

State:

Zip Code:

Residence Address (if different from Mailing Address):

Phone Number(s):

E-mail Address:

Please list all persons living with you for whom you want Medicaid. List yourself if you want Medicaid for yourself.

Is this

Person a

U.S.

Does the

Citizen?

Father of

Does the

(Y/N)

this child

Mother of

(you may

live in

this child

qualify for

your

live in your

Medicaid

Suffix

Sex

Social Security

even if you

home?

First Name

Last Name

(Jr.)

Race

M/F

Date of Birth

Relationship to You

Number

answer No)

(Y/N)

Please list all persons living with you for whom you DON’T want Medicaid. List yourself if you don’t want Medicaid. You do not have to provide a SSN or immigration status information for any person who is not asking for Medicaid. If provided, we will use the SSN for computer matches with other agencies and it may help us process your child’s application. We will NOT share your information with the Department of Homeland Security (formerly the INS).

Is anyone in the household pregnant? Yes No If yes, who is pregnant? _________________________ Due Date: ____________ Please attach verification of pregnancy if available.

Do you have any unpaid medical bills from the past three months? Yes	No If yes, which months? _________________________________________________________________
Does anyone in your household have Health Insurance? Yes No	If yes, list Insurance Company and policy number:

Have you or anyone in your household been diagnosed with Breast or Cervical Cancer? Yes No If yes, have you received Women’s Health Medicaid previously? Yes No

Form 94 (11/10)

INCOME, RESOURCES and DAYCARE

List all income received by persons on page 1 of this application. Be sure to show the amount before deductions. Attach an extra sheet if necessary. We will decide, based on the type of Medicaid, whose income must be counted and whose may be excluded. If you are applying for Children Only or Pregnant Woman Medicaid, you do not have to complete the Resources/Vehicles sections below.

Gross Amount per Pay

How Often?

Amount in

Who Owns

Check

(weekly, every 2-weeks,

Income

(amount before deductions)

monthly, etc.?)

Name of Person Receiving

Resources

Account/Value

Resource?

Wages/Earnings

Cash

Current Employer:

Checking Account

Wages/Earnings

Savings Account

Current Employer:

Credit Union

Social Security

401K/Retirement

Income/SSI

Account

Worker’s

Compensation

Other

Pensions or

Vehicle(s): Cars, trucks, motorcycles (licensed)

Retirement Benefits

Child Support/

Make

Model

Year

Amount

Contributions

Owed?

Unemployment

Benefits

Other Income, please

specify:

Do you pay for dependent care (daycare for a child or care for an adult who cannot care for himself/herself) so that someone in your household can work?

Name of Parent who works

Name of child or adult cared for

Name of care provider

Amount of Payment

How Often? (weekly, 2-weeks,

monthly, etc)

If you are applying for Medicaid for children and one or both of their parents are not in the home, please provide the following information:

Child’s Name

Absent Parent’s Name (Mother/Father)

Do they have Medical Coverage on the Child?

Yes/No

If Yes to Medical Coverage, please list name

of insurance company & group number

I understand that this information may need to be verified to determine eligibility. I understand wage and salary information supplied by the Georgia Department of Labor may be obtained to verify and determine eligibility for Medicaid. I agree to assign to the state all rights to medical support and third party support payments (hospital and medical benefits). I agree to give the State the right to require an absent parent provide medical insurance, if available. I understand I must get medical support from the absent parent if it is available and must cooperate with the Division of Child Support Services in obtaining this support. If I do not cooperate, I understand I may lose my Medicaid benefits, and only my children will receive benefits unless good cause is established. I understand that I must report changes in my income and circumstances within ten (10) days of becoming aware of the change.

I certify under penalty of perjury that I am a U.S. Citizen and/or lawfully present in the United States. If I am a parent or legal guardian, I certify that the applicant(s) is a U.S. Citizen

and/or lawfully present in the United States. I certify to the best of my knowledge and belief that the person(s) for whom I am applying for Medicaid is/are U.S. citizen(s) or are lawfully present in the United States. I further certify that all of the information provided on this application is true and correct to the best of my knowledge.

Signature (Required): ______________________________________________________________________________

Date: ______________________________

Form 94 (11/10)

➤ PDF File

Form Specifications

Fact Name	Details
Non-Discrimination Policy	The application states that it will be considered without regard to race, color, sex, age, disability, religion, national origin, or political belief.
Interview Requirement	A face-to-face interview is not required for Medicaid applications, simplifying the process for applicants.
Assistance Availability	If applicants cannot understand or complete the form, they can notify DFCS staff for free assistance.
Eligibility for Medicaid	Applicants must provide details about all persons living with them who are seeking Medicaid, including their relationship and citizenship status.
Pregnancy Verification	Applicants must indicate if anyone in the household is pregnant and attach verification if available.
Income Reporting	All income received by household members must be reported before deductions. This includes wages, social security, and other income types.
Dependent Care Costs	Applicants can report costs for dependent care, which allows someone in the household to work.
Medical Support Cooperation	Applicants must agree to cooperate with obtaining medical support from absent parents, or they risk losing Medicaid benefits.
Certification of Information	Applicants must certify that all information provided is true and correct, under penalty of perjury.

Georgia Medicaid Application: Usage Guidelines

Once you have gathered all necessary information, you are ready to fill out the Georgia Medicaid Application form. Completing this form accurately is essential to ensure your application is processed efficiently. Take your time, and if you encounter any difficulties, do not hesitate to reach out for assistance.

Obtain the Application Form: You can find the Georgia Medicaid Application form online or request a physical copy from your local Department of Family and Children Services (DFCS).
Fill in Your Personal Information: Start with your name, including your first name, middle initial, last name, and maiden name if applicable. Provide today’s date, mailing address, city, state, zip code, and phone number(s). Include your email address if you have one.
List Household Members: Identify all individuals living with you who you want to apply for Medicaid. For each person, provide their name, date of birth, relationship to you, and whether they are U.S. citizens.
Indicate Pregnancy Status: If anyone in your household is pregnant, answer “Yes” and provide the name of the pregnant person and their due date. Attach verification of pregnancy if available.
Report Unpaid Medical Bills: If you have unpaid medical bills from the past three months, indicate “Yes” and specify which months.
Provide Insurance Information: If anyone in your household has health insurance, check “Yes” and list the insurance company and policy number.
Detail Income and Resources: List all income received by those in your household, ensuring to show the gross amount before deductions. Include details about any resources or vehicles owned, if applicable.
Dependent Care Expenses: If you pay for daycare or care for someone who cannot care for themselves, provide the details, including the name of the caregiver and the amount paid.
Complete Certification: Read the certification statement carefully. By signing, you confirm that the information provided is accurate and complete. Include your signature and the date.

After completing the form, review it thoroughly to ensure all information is accurate and complete. Submit the application to your local DFCS office, and keep a copy for your records. You will receive further instructions regarding your application status and any additional steps needed.

Your Questions, Answered

What is the purpose of the Georgia Medicaid Application form?

The Georgia Medicaid Application form is used to apply for Medicaid benefits in the state of Georgia. It collects essential information about the applicant and their household to determine eligibility for various Medicaid programs, including those for pregnant women and families with children.

Do I need to have a face-to-face interview to apply?

No, a face-to-face interview is not required for Medicaid applications. You can complete the application process without attending an in-person meeting. If you have questions or need assistance while filling out the form, you can contact the Division of Family and Children Services (DFCS) for help at no charge.

What information do I need to provide about my household?

You will need to list all individuals living with you for whom you want Medicaid coverage. This includes yourself and any children or adults in your care. You must provide details such as their names, social security numbers, relationship to you, and whether they are U.S. citizens. Additionally, you should indicate if anyone in your household is pregnant or has health insurance.

What should I do if I have unpaid medical bills?

If you have unpaid medical bills from the past three months, you should indicate this on the application. You will need to specify which months these bills pertain to. This information may help in determining your eligibility for Medicaid coverage.

How does income affect my Medicaid application?

Income is a critical factor in determining eligibility for Medicaid. You must list all sources of income for everyone in your household on the application. This includes wages, social security, and any other financial support. Be sure to provide the gross amount before any deductions. If you are applying for Medicaid for children or pregnant women, you do not need to complete the resources section.

What happens if my circumstances change after I apply?

You are required to report any changes in your income or circumstances within ten days of becoming aware of the change. This includes changes in employment, household composition, or any other relevant factors that could impact your eligibility for Medicaid benefits.

Is my personal information kept confidential?

Yes, your personal information is treated with the utmost confidentiality. The information you provide on the application will not be shared with the Department of Homeland Security. It is used solely for the purpose of determining your eligibility for Medicaid benefits.

Common mistakes

Incomplete Information: Failing to provide all required details can delay the application process. Each section of the form must be filled out completely. Missing information can lead to unnecessary follow-ups and potential denial of benefits.
Incorrect Personal Details: Errors in names, dates of birth, or Social Security numbers can create significant issues. Double-checking these details before submission is crucial to ensure accuracy.
Neglecting to Report Income: Omitting income sources or underreporting amounts can result in an inaccurate assessment of eligibility. All income must be disclosed, including wages, benefits, and any other financial support.
Failure to Attach Required Documentation: Not providing necessary verification documents, such as proof of pregnancy or income, can lead to delays. Ensure all supporting documents are included when submitting the application.
Ignoring Changes in Circumstances: Once the application is submitted, any changes in income or household status must be reported promptly. Failing to do so can affect ongoing eligibility and benefits.

Documents used along the form

When applying for Medicaid in Georgia, it’s essential to gather several supporting documents alongside the application form. These documents help verify your information and streamline the approval process. Here’s a list of commonly required forms and documents that you may need to submit with your Georgia Medicaid Application.

Proof of Identity: A valid form of identification, such as a driver’s license or passport, is necessary to confirm your identity. This helps ensure that the application is processed accurately and securely.
Income Verification: Documents such as pay stubs, tax returns, or Social Security statements are crucial. They provide proof of your income and help determine your eligibility for Medicaid benefits.
Proof of Residency: A utility bill, lease agreement, or bank statement can serve as proof of your current address. This document confirms that you reside in Georgia, which is a requirement for Medicaid eligibility.
Medical Records: If applicable, providing medical records can be important, especially if you are applying for specific programs like Women’s Health Medicaid. These records help verify any medical conditions that may influence your eligibility.

Gathering these documents ahead of time can make the application process smoother and help ensure that you receive the benefits you need. Always check with local Medicaid offices for any additional requirements specific to your situation.

Similar forms

Food Stamp Application: Similar to the Georgia Medicaid Application, the Food Stamp Application requires personal information about household members, income details, and verification of eligibility. Both forms aim to assess financial need and support for low-income individuals and families.
Temporary Assistance for Needy Families (TANF) Application: This application also gathers information about household composition, income, and resources. Like the Medicaid application, it is designed to determine eligibility for financial assistance programs.
Supplemental Security Income (SSI) Application: The SSI application requires detailed information about income, resources, and living arrangements, similar to the Medicaid form. Both applications focus on assessing need and eligibility for financial support.
Children’s Health Insurance Program (CHIP) Application: Much like the Medicaid application, the CHIP application collects information about family size, income, and health coverage. Both programs aim to provide health insurance for children from low-income families.
Housing Assistance Application: This application requires personal and financial information to determine eligibility for housing assistance. Similar to the Medicaid application, it assesses the applicant's financial situation to provide necessary support.
Unemployment Benefits Application: The unemployment benefits application gathers details about employment history and income. Like the Medicaid application, it evaluates the applicant's financial need and eligibility for assistance.
Low-Income Home Energy Assistance Program (LIHEAP) Application: This application collects information about household income and size, similar to the Medicaid form. Both aim to assist low-income families in meeting essential needs.
Veterans Affairs Benefits Application: The VA benefits application requires personal and financial information to determine eligibility for veterans' assistance. This process is akin to the Medicaid application in its focus on assessing individual needs.
State Disability Benefits Application: This application collects information about medical conditions and financial status, similar to the Medicaid application. Both are designed to evaluate eligibility for support based on need.
School Meal Program Application: The school meal program application gathers information about household income and family size. Like the Medicaid application, it aims to provide support to families in need of assistance for their children's nutrition.

Dos and Don'ts

When filling out the Georgia Medicaid Application form, there are some important things to keep in mind. Here’s a helpful list of what you should and shouldn’t do:

Do answer all questions completely and accurately.
Do notify DFCS staff if you need help understanding or completing the application.
Do provide your current mailing and residence addresses.
Do report any changes in your income or circumstances within ten days.

Don't leave any sections blank unless instructed to do so.
Don't provide information for individuals who are not applying for Medicaid.
Don't forget to sign and date the application before submitting it.
Don't hesitate to ask for assistance if you find any part of the application confusing.

Misconceptions

Misconception 1: A face-to-face interview is required for the application.

This is not true. The application process does not require an in-person interview. You can complete the application without attending an interview.

Misconception 2: Only certain races or groups can apply for Medicaid.

This is incorrect. The application states that it will be considered without regard to race, color, sex, age, disability, religion, national origin, or political belief.

Misconception 3: You must provide a Social Security Number for everyone in your household.

You only need to provide a Social Security Number for those applying for Medicaid. If someone is not applying, you do not have to include their SSN.

Misconception 4: You cannot apply if you have health insurance.

This is false. Having health insurance does not disqualify you from applying for Medicaid. You simply need to report your insurance information.

Misconception 5: You cannot apply for Medicaid if you have unpaid medical bills.

This is not the case. You can still apply for Medicaid even if you have unpaid medical bills from the past three months.

Misconception 6: You need to have a lawyer to fill out the application.

You do not need a lawyer. The application process is designed for individuals to complete on their own. Assistance is available if needed.

Misconception 7: The application process is too complicated to understand.

The application is straightforward. It is designed to be user-friendly, and help is available if you have questions.

Misconception 8: You must report all income, regardless of the type of Medicaid you are applying for.

This is not entirely true. If you are applying for Children Only or Pregnant Woman Medicaid, you do not have to complete the resources and vehicles sections.

Misconception 9: You cannot apply if you have been diagnosed with a serious illness.

This is incorrect. A diagnosis does not prevent you from applying for Medicaid. In fact, there are specific programs for individuals with certain health conditions.

Misconception 10: You will lose your Medicaid benefits if you don’t report changes immediately.

While it is important to report changes within ten days, losing benefits is not automatic. There may be options to address any issues that arise.

Key takeaways

Key Takeaways for Filling Out the Georgia Medicaid Application Form

The application does not consider race, color, sex, age, disability, religion, national origin, or political belief.
A face-to-face interview is not required, making the process more accessible.
Complete all questions accurately; assistance is available if needed at no cost.
List all individuals living with you who require Medicaid, including yourself if applicable.
Provide information about income and resources, but note that some sections may be skipped for specific applications, like Children Only or Pregnant Woman Medicaid.
Report any changes in income or circumstances within ten days to avoid potential loss of benefits.