Medicaid Application English - Florida Department of Health

f!;Acc~ss Application

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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):

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Date Stamp: ___________

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Case Number:

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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 ................
................

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