Medical Benefits Renewal Form - Oregon

This Oregon-specific "Medical Benefits Renewal Form" is a document released by the Oregon Department of Human Services.

Download the fillable PDF by clicking the link below and use it according to the applicable legal guidelines.

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Program: Branch: Case number:
Worker ID:
Case name:
Date of request:
Please return by this date:
It’s time to renew your medical benefits.
• We need to get information from you to see if you are still eligible. You can call
us with this information or return this form.
• Please let us know if you have questions about this form or if you need help or
more time to get proof. Call the number at the top of the page. You may call
collect, if necessary.
If we do not hear from you by
, your medical benefits will end. We
will send you another notice before ending medical benefits.
We will complete a review of medical benefits for:
DOB:
,
DOB:
DOB:
,
DOB:
DOB:
,
DOB:
When you see this arrow, it means you may have to send in a document that
shows us the information you gave is correct. For instance, we will need proof of
income and pregnancy.
Please send any needed proof to the address listed at the top of this page.
Does your partner, spouse, a family member or someone you live with make you
afraid by threatening, yelling or physically hurting you or your children?
 Yes
 No
?
?
Need help?
Please call your worker. The phone number is at the top of the first page.
Page 1
OHA 0945 (06/12)
Program: Branch: Case number:
Worker ID:
Case name:
Date of request:
Please return by this date:
It’s time to renew your medical benefits.
• We need to get information from you to see if you are still eligible. You can call
us with this information or return this form.
• Please let us know if you have questions about this form or if you need help or
more time to get proof. Call the number at the top of the page. You may call
collect, if necessary.
If we do not hear from you by
, your medical benefits will end. We
will send you another notice before ending medical benefits.
We will complete a review of medical benefits for:
DOB:
,
DOB:
DOB:
,
DOB:
DOB:
,
DOB:
When you see this arrow, it means you may have to send in a document that
shows us the information you gave is correct. For instance, we will need proof of
income and pregnancy.
Please send any needed proof to the address listed at the top of this page.
Does your partner, spouse, a family member or someone you live with make you
afraid by threatening, yelling or physically hurting you or your children?
 Yes
 No
?
?
Need help?
Please call your worker. The phone number is at the top of the first page.
Page 1
OHA 0945 (06/12)
Case name:
Case number:
Date of request:
Tell us about the people in your household
1. We show the following people as living in your house.
Name
Date of birth
Has this person
Wants medical
moved out?
benefits?
*
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
 Yes
 No
Check yes if this person would like to renew or apply for medical benefits.
*
 Yes
 No
2. Has anyone moved into your house?
If yes, complete the section below.
List people who moved in only
:
Person 1: Name
(first, middle initial, last)
Date this person moved in:
This is my:
Sex:
 husband or wife  child
 Female
 step child  other: ___________________
 Male
City of birth:
State of birth:
Social Security number (SSN)
Date of birth
:
(month, day, year)
Are you applying for health coverage for this person?
 Yes
 No
If yes, you must tell us about citizenship and Social Security or
If you do not have a SSN check
Is this person a U.S. citizen?
immigration status:
 Yes  No
this box 
If no, and this person has an Alien
Resident number, write it here:
Is this person Alaska Native or a member of a federally recognized American Indian tribe?
 Yes  No
Does this person receive services through Indian Health Services?
 Yes  No
Is this person the parent of a child who is living with you?
 Yes  No
Ethnicity:
 Hispanic or Latino
 Not Hispanic or Latino
Your answers to ethnicity and
Race
(choose one or more):  American Indian or Alaska Native
race questions help us, but you
 Asian
 White
 Black or African American
can choose not to answer them.
 Native Hawaiian or other Pacific Islander
*Use another sheet of paper if you need to write about more people.
3. Have you moved in the last year?  Yes
 No, If yes, please complete below.
New home address:
City:
ZIP code:
New mailing address (if different):
City:
ZIP code:
?
?
Need help?
Please call your worker. The phone number is at the top of the first page.
Page 2
OHA 0945 (06/12)
Case name:
Case number:
Date of request:
4. Pregnancy. Please tell us about anyone in your home who is pregnant (including yourself or
anyone related to you or your children).
You must send proof. Please send a copy of a letter from a doctor or clinic saying this
person is pregnant.
Due date
Does the baby’s father
Name
(month, day, year)
live in your home?
st
1
person:
 yes  no If yes, what is his name?
nd
2
person:
 yes  no If yes, what is his name?
5. Please tell us about anyone in your home (related to you or your children and 16 years or older)
who is in high school, college or technical or vocational school. We will contact you if we
need proof.
Does the school consider this
Name
School name
student full or part time?
st
1
person:
 Full time  Part time
nd
2
person:
 Full time  Part time
rd
3
person:
 Full time  Part time
6. Absent parents. Answer if you are applying for any child under age 19 (including expected
children) whose parents are absent. Absent parents are parents who do not live in the
household, including parents who are in jail.
Absent parent
Name (first, middle initial, last):
This is my:  spouse or ex-spouse
 child
 partner or ex-partner
 step child
 other: _________________________________
Date of birth: (month, day, year):
Sex:  Female
Social Security number (if you know it):
 Male
Address:
City:
State:
ZIP code:
Date this parent stopped living with child (month, day, year):
Phone:
Hours each week this parent spends with
List this parent’s children
the child in the child’s home:
(if you have included those
children on this application).
If this is an absent father, has paternity been legally established?
 Yes
 No
 I don’t know
Can the child or children get health insurance through this parent?
 Yes
 No
 I don’t know
Do you think this parent might hurt you or the child if we try to find
out about paternity or health insurance?
 Yes
 No
*Use another sheet of paper if you need to write about more absent parents.
?
?
Need help?
Please call your worker. The phone number is at the top of the first page.
Page 3
OHA 0945 (06/12)
Case name:
Case number:
Date of request:
Income information
1. Does anyone in your home get money for working?
 Yes  No
If yes, complete below.
Please tell us about wages, salaries and commissions for this month from jobs. We need to know
about money that has already been paid or that will be paid this month to anyone in your home
who is related to you or your children (including expected children). Use gross income (totals
before taxes and deductions).
You must send proof. Please send a copy of the most recent pay stub, or a pay stub received
within the last 30 days, for each job listed.
Self-employment means you are being paid for doing work, but you don’t have a regular employer
other than yourself who gives you a paycheck and takes out taxes. Perhaps you have your own
company with a separate bank account, or perhaps you do odd jobs for people who pay you
in cash.
Does anyone in your home get money for self-employment?
 Yes  No
If yes, please complete question two in this section.
Tell us about any money expected from work:
Job 1
Who earns money from this job?
What person, business or agency pays this person?
How many hours
How much gross income will
Does this job pay hourly?
 Yes
 No
each week?
this job pay? (Fill in below):
If yes, how much each hour? ___________
This job pays:
this month?
next month?
 every week
 every 2 weeks
 every month
Job 2
Who earns money from this job?
What person, business or agency pays this person?
How many hours
How much gross income will
Does this job pay hourly?
 Yes
 No
each week?
this job pay? (Fill in below):
If yes, how much each hour? ___________
This job pays:
this month?
next month?
 every week
 every 2 weeks
 every month
Job 3
Who earns money from this job?
What person, business or agency pays this person?
How many hours
How much gross income will
Does this job pay hourly?
 Yes
 No
each week?
this job pay? (Fill in below):
If yes, how much each hour? ___________
this month?
next month?
This job pays:
 every week
 every 2 weeks
 every month
Please use another sheet of paper if you need to write about more jobs.
?
?
Need help?
Please call your worker. The phone number is at the top of the first page.
Page 4
OHA 0945 (06/12)
Case name:
Case number:
Date of request:
2. Tell us about any money from self-employment:
Send all available proof of income and expenses for the most recent month available.
Proof could be bookkeeping records, contracts, work agreements, payroll records or sales
receipts. Tax returns may also be accepted if no other proof is available.
Business name:
What does this business do?
Is this business incorporated?  Yes  No
Is your office located within your home?  Yes  No
Business address:
City:
State:
Business phone number:
Gross income expected this
Gross income expected next
month (before costs)?
month (before costs)?
1
business expense: Kind of expense
How much this month? How much next month?
st
2
nd
business expense: Kind of expense
How much this month? How much next month?
3
rd
business expense: Kind of expense
How much this month? How much next month?
4
th
business expense: Kind of expense
How much this month? How much next month?
5
th
business expense: Kind of expense
How much this month? How much next month?
Please use another sheet of paper if you need to write about more businesses or expenses.
3. Please tell us about money for this month and next month that does not come from work.
If yes, tell us about this month’s and next month’s income for anyone in your home who is
related to you or your children (including expected children).
You must send proof. Proof could be copies of check stubs, award letters, or
other written proof.
Tell us about money, including:
• rent paid to you
• loans repaid to you
• guardian or foster care payments
• tribal payments
• worker’s compensation
• Supplemental Security Income (SSI)
• disability benefits
• child or spousal support
• unemployment compensation
• veteran’s benefits
• Social Security benefits
• dividends or interest on investment
• retirement pension
• educational income (such as financial aid)
• Temporary Assistance for Needy Families (TANF)
• other: _______________________
Please list money that does not come from work:
1
st
kind of income: Write kind of income here.
Who gets this income? How much gross income:
this month? next month?
What person, business or agency pays this person?
How often?
 Every week
 Every 2 weeks
 Every month
2
nd
kind of income: Write kind of income here.
Who gets this income? How much gross income:
this month? next month?
What person, business or agency pays this person?
How often?
 Every week
 Every 2 weeks
 Every month
Please use another sheet of paper if you need to tell us about more money form other places.
?
?
Need help?
Please call your worker. The phone number is at the top of the first page.
Page 5
OHA 0945 (06/12)

Download Medical Benefits Renewal Form - Oregon

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