REQUEST TO ADD FAMILY MEMBERS TO A KIDCARE CASE



REQUEST FOR MEDICAL BENEFITS FOR ANOTHER FAMILY MEMBER(S)

Before completing this form, please read the instructions on the other side.

Name on the front of the MediPlan or KidCare ID Card __________________________________________________

Address: ________________________________________________Phone Number____________________

Case Number on MediPlan or KidCare ID Card #: 9 - - Csld on MediPlan Card (if known) ___________

|I would like to request medical benefits for the person(s) named below |Person #1 |Person #2 |

|Name (Last, First) | | |

|Sex |( Male ( Female |( Male ( Female |

|Birth date (Month / Day / Year) | | |

|Social Security Number | | |

|Relationship to the person completing this form | | |

|Is this person an Alaska Native or American Indian? |( Yes ( No |( Yes ( No |

|If this person is under age 19, enter: | | |

|a. Mother’s full name |a. |a. |

|b. Father’s full name |b. |b. |

|Has this person received any medical care in the past 3 months you want the State to pay for? If |( Yes ( No |( Yes ( No |

|yes, which months? Attach one pay stub from each job or 30 days self-employment records | | |

|Is this person pregnant? If yes, please attach a doctor’s statement. |( Yes ( No |( Yes ( No |

|Is this person covered by health or hospital insurance including Medicare now or in the last three |( Yes ( No |( Yes ( No |

|months? If yes, complete the following: | | |

|a. Insurance begin date and end date if insurance ended |a. |a. |

|b Does your insurance cover doctor visits and hospital stays? |b. |b. |

|c. Name of Insurance Company |c. |c. |

|d. Name of Policyholder |d. |d. |

|e. Policyholder’s SSN (optional) |e. |e. |

|Employer Name and Phone Number. |f |f. |

|Policy Number and Group Number |g. |g. |

|Is this COBRA Insurance? |h. |h. |

|Relationship to policyholder |i. |i. |

|j. If insurance ended, tell us why. |j. |j. |

|U.S. Citizen? If the person is a U.S. citizen attach proof. If not a citizen, enter their Alien |Yes ( No |Yes ( No |

|(A) number and attach proof. Children who do not have an Alien Registration Number may still be | | |

|eligible. | | |

|Does this person or their spouse receive income through employment? If yes, complete the following |( Yes ( No |( Yes ( No |

|and attach one pay stub from each job for each month listed or 30 days of income and expense records| | |

|for self-employment. |a. |a. |

|a. Name of Employer |b. |b. |

|b. Employer Address and Phone |c. |c. |

|c. Number of hours worked weekly |d. |d. |

|d. Amount Paid (including tips) before taxes |e. |e. |

|e. How often paid |f. |f. |

|f. Day Care Expenses (enter amount, how often paid) | | |

|Does this person or their spouse receive any other income such as child support, interest from trust|( Yes ( No |( Yes ( No |

|funds, pensions, rental income, SSA, SSI, etc.? If yes, list and attach proof. | | |

|a. Type |a. |a. |

|b. Monthly Amount $ |b. |b. |

|Does this person pay child support or spousal support? If yes, enter amount, how often paid and |( Yes ( No |( Yes ( No |

|attach proof. | | |

I certify that the above information is true to the best of my knowledge and belief.

Signed __________________________________________________________________ Date ___________________

DPA 243C (N-02-06) IL478-0048

REQUEST FOR MEDICAL BENEFITS FOR ANOTHER FAMILY MEMBER(S)

Instructions

Who Can Get Medical Benefits with this Form?

If your child gets a KidCare ID or MediPlan card, you can use this form to ask for benefits for:

✓ A child when their parents or other siblings already get medical benefits

✓ a parent living with their children 18 years old or younger when one of the children already gets medical benefits;

✓ another relative who is caring for children in place of their parents when one of the children already gets medical benefits.

Who Should Complete and Sign This Form?

This form should be completed and signed by the person whose name is on the front of your MediPlan or KidCare ID Card. Please answer all questions for all persons who want medical benefits.

You will need information about the family members you would like to add to your KidCare Id or MediPlan card.

Send the following items for the person you want to add to medical benefits. If you want All Kids for a child, you do not have to send your proof of income or your spouse’s proof of income.

Proof of citizenship

✓ Copy of a U.S. birth certificate, a hospital record of birth, a U.S. passport, a Certificate of Naturalization or a Certificate of Citizenship.

Social Security Number

✓ Write in the person’s Social Security Number. Children who cannot get a Social Security Number can still get All Kids.

Income from the person for whom you want medical benefits.

✓ One pay stub from each job or proof of one payment from each source of income the adult received in the last 30 days. If the adult is self-employed provide business records that include income and expenses for the last 30 days.

✓ Proof of one payment from each source of income if your child got income directly in the last 30 days.

If you or your spouse pay spousal support or child support

✓ Proof of one payment made in the last 30 days.

If anyone is not a U.S. citizen but has an Alien Registration Number

✓ Write the Alien Registration Number if they have one. Give us a copy of immigration papers showing immigration status if you have them. Children who are not citizens and do not have Alien Registration Numbers can still get All Kids.

If anyone in your family is pregnant

✓ A signed statement from a doctor or health clinic with the expected date of delivery and the number of babies expected.

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