Medicaid Application English - Florida Department of Health
f!;Acc~ss Application
Flonda
Do you have a reason that makes it difficult for you to come to the office for an interview?
D Illness DTransportation Dwork or Training D Live in a Rural Area D Care for a
sick or Disabled Household Member D Other (explain):
{j't
;.
\.,_
Date Stamp: ___________
i
~""..
Case Number:
??tUOMIII.IIIIbWot
I would like to apply for: D Food Assistance Dcash D Relative Caregiver DOSS/Optional State Supplementation DMedical D Medicaid Waiver/Home & Community
Based Services DHospice D Nursing Home Care- Living address prior to entering Nursing Home:
EXPEDITED FOOD ASSISTANCE- Eligible households may receive food assistance benefits within 7 days
Welcome to the Florida Department of Children and Families (DCF). If you need help in completing this
application or need interpreter services, please contact ACCESS Florida at 1-BGG-762-2237. We need at
Is your household's gross income less
Do you pay to heat or cool
DYES 0NO your home?
DYES 0NO
least your name, address, and a signature. Processing begins the daywe receiveyour signed application. House? than $150?
hold members Vutlo are ineligible, or Vutlo are not applyingfor benefits, may be designated as non-applicants. Non- Areyour total liquid assets (such as cash,
What is the monthly amount
DYES 0NO of your rent or mortr:~ar:~e?
$
applicants, or persons applying only forE mergency Medicaid, Refugee Cash Assistance, or Refugee Medical
bank accounts, etc) less than $1 00?
Assistance, are NOT required to provide a Social Security Number (SSN) based on the Food Stamp Act. If you Is your household's monthly gross
Has all of your household's
are not eligiblefor an SSN because ofyour immigration status, you may be eligible for a non-work SSNto receive
income recently stopped?
income plus your total liquid assets less
DYES 0NO
the benefits that require one. If you need an SSN, we can help you apply for one. Non-applicants are NOT
than your monthly rent or mortgage plus DYES 0NO If yes, WHEN?
required to provide proof of immigration status. Noncitizens Vutlo are applying for benefits will have their immigra?
utilities?
lion status verified with the United States Citizenship and Immigration Services (USCIS). We will not tell USCIS
Is anyone in your household a
about the immigration status ofthose living in your household Vutlo are not applyingfor benefits. Under no circum? Check the billsyou pay: D Electricity 0Gas
migrant or seasonal farm worker?
DYES 0NO
stances will individuals Vutlo are not applying for benefits be reported as not I ................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- application for mo healthnet medicaid
- washington apple health application for long term care
- maryland department of health application medicaid home
- application for medicaid and affordable health coverage
- application for apple health medicaid health care coverage
- application for assistance
- application for ahcccs health insurance and medicare
- wisconsin medicaid for the elderly blind or disabled
- medicaid application department of health
- application for aged blind disabled long term care coverage