Family Planning Benefit Program
Application
Please print this out and bring to Planned Parenthood for your
visit.
| Section A: Contact Information | Tell us who you are and how to contact you | ||||
| First name: |
Middle Initial: |
Last Name: |
Primary Language
Spoken: |
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| Home Address: |
County |
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| If you do not want to receive mail or a benefit card at your home address, give a different address below: | |||||
| Mailing Address: (if
different) |
County: |
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| Phone number(s)
where you can be reached:
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Is anyone in the
household a veteran? If YES, name:
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| Does anyone who is
applying have family planning bills from the last three
months?
Yes_______
No_______ The Family Planning Benefit Program may be able to help pay them. |
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| Do you need to keep these services confidential? Yes_______ No_______ | |||||
| Section B: Household Information | List the names of everyone applying. If you are applying, list yourself first. List other people who are living with you even if they are not applying. You must list your spouse and you may list your children. | ||||||
| First Name, Middle Initial | Birth
Date (MM/DD/YY) |
Sex M/F | Relationship to person on line 1 | Is this person applying for family planning benefits? (Y/N) |
Applicants only |
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| Social Security No. | Race/Ethnic Group (see codes) | ||||||
| 01 |
Self |
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| 02 | |||||||
| 03 | |||||||
| 04 | |||||||
|
Race/Ethnic Affiliation
Codes: (optional) |
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| Section C: Household Income | List the types of money and the amount received by anyone listed in Section B. Be sure to include earnings from work, child support payments, unemployment benefits, interest, Social Security benefits, pensions, disability payments, money from relatives or friends, or other payments. | ||||||
| Name
of person working or receiving money: |
Types
of income (example: wages) |
How
much does the person receive before taxes? |
How
often is the income received? (weekly, every two weeks, monthly, other) |
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| If no income, please explain how you are meeting your needs (for example, living with a friend or relative): | |||||||
| Do you have to pay for child care (or for care for a disabled child or disabled adult) in order to work or go to school? Yes_______ No_______ | |||||||
| If yes to above question: | Name(s): | Cost? | How often (monthly, weekly, etc.) | ||||
| Section D: Citizenship | This information is needed for those people applying for family planning benefits: | ||
| Is everyone applying a U.S. Citizen? (If yes, skip to section E) Yes_______ No_______ | |||
| If NO, please give the following information for anyone applying for family planning benefits who is not a U.S. Citizen. Your answers to these questions will be kept completely confidential. | |||
| First, middle and last names. | Does this person belong to any of the categories listed below? Check the appropriate line. | If A or B, on what date did the person enter the United States? (mm/dd/yy) | |
| A_______ B_______ None_______ | |||
| A_______ B_______ None_______ | |||
| A. Check A if the
person is under one of the following categories:
Legal permanent resident (green card
holder) |
B. Check B if the
person is under one of the following categories:
Order of Supervision Stay of
Deportation Supervision of Deportation |
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| Section E: Health Insurance | You may still be eligible even if you have other health insurance. |
| Does anyone applying
have Medicaid, Family Health Plus or Child Health Plus? If YES, give the
names of anyone with coverage:
|
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| Does anyone have
other health insurance that covers a person applying for the Family
Planning Benefit Program? Yes_______ No_______ Don't Know_______ |
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| If YES: Persons Covered: | |
| Name of policy holder: | Group Policy # |
| Insurance company name: | Monthly cost: |
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TERMS,
RIGHTS AND RESPONSIBILITIES I
understand that I must provide the information needed to prove my
eligibility. If I have been
unable to get the information, I will tell the social services district.
The social services district may be able to help in getting the
information. I
understand the FPBP may check the information given by me for this
application. The state, social
services district and provider who assist in completing this application
will keep this information confidential according to 42 U.S.C. 1396a(a)(7)
and 42 CFR 431.300-431.307, and any federal and state laws and
regulations. I
understand that my eligibility for this program will not be affected by my
race, color, disability, sex, or national origin.
I also understand that depending on the requirements of this
program, my age or citizen status may be a factor in whether or not I am
eligible. I
understand that anyone who knowingly lies or hides the truth in order to
receive services under this program is committing a crime and subject to
federal and state penalties and may have to repay the amount of benefits
received and be given civil penalties. ASSIGNMENT
OF RIGHTS FOR MEDICAL SUPPORT AND THIRD PARTY PAYMENT I understand
that FPBP does not pay medical expenses that insurance or another person
is supposed to pay, unless there is good cause not to use other insurance.
All persons applying for FPBP are required to give to the Medicaid
agency any rights they may have to medical support or other insurance
payments for family planning services.
When I sign this application for myself, or for another person for
whom I can legally give away rights, I am giving to the Medicaid agency
all of my rights to receive medical support and third party payments for
family planning for the entire time I am on Medicaid. REIMBURSEMENT
OF MEDICAL EXPENSES I understand
that I have a right as part of my FPBP application to request
reimbursement of expenses I paid for covered family planning services and
supplies received during the three month period prior to the month of my
application, but no earlier than October 1, 2002.
After the date of my application, reimbursement of covered family
planning services and supplies will only be available if obtained from
Medicaid-enrolled providers. SOCIAL
SECURITY NUMBER (SSN) I understand
that I must give my SSN in order to receive FPBP.
This is required by section 1137(a) of the Social Security act and
the Medicaid regulations (42 CFR 435.910 and 42 U.S.C. 1320b-7(a)).
The FPBP will use the SSN to verify my income, eligibility, and the
amount of medical assistance payments made on my behalf.
The information may be matched with the records in other agencies,
such as the Social Security Administration or the internal Revenue
Service. CONFIDENTIALITY
STATEMENT All of the information you provide to use will remain confidential. The only people who will see this information are the state or local agencies and the person assisting you in completing the application who need to know this information in order to determine if you are eligible. The person helping you with this application cannot discuss the information with anyone, except a supervisor or the state or local agencies that need this information. |
| I certify that I am a U.S.
Citizen or national, or an alien with satisfactory immigration status. The
social services district can assist me in determining my status if I
request help.
Date:____________________________ Applicant's Signature:_______________________________________________ Immigration information: The Immigration and Naturalization Service (INS) has said that enrollment in Medicaid CANNOT affect a person's ability to get a green card, become a citizen, sponsor a family member, or travel in and out of the country (except if Medicaid pays for long term care in a place like a nursing home or psychiatric hospital). The State will not report any information on this application to the INS. |
| I certify that I have read
and understand the Terms, Rights and Responsibilities above. I certify
under penalty of perjury that everything on this application is the truth
as best I know.
Date:____________________________ Applicant's Signature:_______________________________________________ Spouse's Signature (if applying):_______________________________________________ |
| Declination of Medicaid and
Family Health Plus Determinations:
I, _______________________________________________, have been informed of the benefits available under Medicaid and Family Health Plus. I choose not to apply for Medicaid and Family Health Plus at this time, and have requested an eligibility determination for the Family Planning Benefit Program only. I understand that I may apply for these other programs in the future if I wish. Date:____________________________ Applicant's Signature:_______________________________________________ Provider/Medicaid Staff Signature:_______________________________________________ |
| IF AFTER READING AND
COMPLETING THIS FORM, YOU DECIDE THAT YOU DO NOT WANT TO APPLY FOR THE
FAMILY PLANNING BENEFIT PROGRAM, SIGN your name below.
Date:____________________________ I consent to withdraw my application:____________________________________________ |
| FOR OFFICE USE ONLY:
To be completed by the person assisting with the application:
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