Form 403 "Application for Health Insurance" - Delaware

What Is Form 403?

This is a legal form that was released by the Delaware Health and Social Services - a government authority operating within Delaware. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on February 1, 2011;
  • The latest edition provided by the Delaware Health and Social Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form 403 by clicking the link below or browse more documents and templates provided by the Delaware Health and Social Services.

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Download Form 403 "Application for Health Insurance" - Delaware

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Diamond
State
APPLICATION FOR HEALTH INSURANCE
Health
Plan
Complete and sign this application form to apply for the Delaware
Last Name
First Name
M.I.
Healthy Children Program, Medicaid, or the Medicare Beneficiary
Savings Program.
Street Address
Apt. No.
Return this application within 30 days of the date you asked for
health insurance. If you do not, this may change the date your
health insurance will start.
City
State
Zip Code
We need you to give us proof of the following items:
One Month of Family Income (pay stubs, award letters)
Self-employment (complete tax return including all schedules)
Do you plan to stay in Delaware?
Lawful alien status (copy of front/back of card, papers)
Daytime Telephone Number
Birth Date (for newborns only)
Pregnancy
Mailing Address (if different from above)
Copy of Medicare card
Pregnant women only need to state family income and provide
medical proof of pregnancy. Other verification must be given
Please list any other names that you may have used
within 30 days.
Do not wait to send in your application if you do not have all the
For Office Use Only
information. We will review your application and if more
Date of Inquiry
Referral Source
information is needed, we will tell you. Once we get all the
information we need, a written notice of decision will be sent to
you.
?
If you have questions, please call:
Applicants who are approved for Medicaid’s Diamond State
Health Plan or the Delaware Healthy Children Program must
Division of Medicaid & Medical Assistance
1-800-372-2022
enroll in a managed care organization. An enrollment information
Health Benefits Manager
1-800-996-9969
packet that explains benefits will be sent to you. Applicants who
are approved for the Medicare Beneficiary Savings Program
Remember to sign and date the back of this application
cannot enroll in a managed care organization.
Diamond
State
APPLICATION FOR HEALTH INSURANCE
Health
Plan
Complete and sign this application form to apply for the Delaware
Last Name
First Name
M.I.
Healthy Children Program, Medicaid, or the Medicare Beneficiary
Savings Program.
Street Address
Apt. No.
Return this application within 30 days of the date you asked for
health insurance. If you do not, this may change the date your
health insurance will start.
City
State
Zip Code
We need you to give us proof of the following items:
One Month of Family Income (pay stubs, award letters)
Self-employment (complete tax return including all schedules)
Do you plan to stay in Delaware?
Lawful alien status (copy of front/back of card, papers)
Daytime Telephone Number
Birth Date (for newborns only)
Pregnancy
Mailing Address (if different from above)
Copy of Medicare card
Pregnant women only need to state family income and provide
medical proof of pregnancy. Other verification must be given
Please list any other names that you may have used
within 30 days.
Do not wait to send in your application if you do not have all the
For Office Use Only
information. We will review your application and if more
Date of Inquiry
Referral Source
information is needed, we will tell you. Once we get all the
information we need, a written notice of decision will be sent to
you.
?
If you have questions, please call:
Applicants who are approved for Medicaid’s Diamond State
Health Plan or the Delaware Healthy Children Program must
Division of Medicaid & Medical Assistance
1-800-372-2022
enroll in a managed care organization. An enrollment information
Health Benefits Manager
1-800-996-9969
packet that explains benefits will be sent to you. Applicants who
are approved for the Medicare Beneficiary Savings Program
Remember to sign and date the back of this application
cannot enroll in a managed care organization.
*Race Code:
I=American Indian/Alaskan Native; B=Black/African American;
1. HOUSEHOLD MEMBERS: Tell us who lives in your household
PI=Native Hawaiian/Pacific Islander; W=White; A=Asian
**Ethnic Code:
H=Hispanic/Latino; N=Non-Hispanic/Latino
Legal
*Race /
Social Security
Alien and
How is this person
Are you
State
U.S.
**Ethnic
Number
Date of
related to you?
applying
and
Citizen
Last Name
First Name
M
Sex
Group
Entry into
(spouse, child,
for this
Date of
For
I
U.S.
stepchild, friend)
person?
Birth
applicants
Optional
For applicants
For
applicants
SELF
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
Yes No
Yes
No
Yes
No
Yes No
Yes
No
Yes
No
Yes No
Answer the questions below if a parent of any child applying does not live in your home. This is for medical support only.
See explanation on the back of this form. If you do not answer, your children may still be eligible.
Child’s Name
Absent Parent’s Name
Absent Parent’s Address
Absent Parent’s Employer
Is anyone in the household pregnant? Name:____________________________Due Date:________How many babies are expected? ____________
2. EARNED INCOME: Tell us about your family’s earnings from paychecks, tips, self-employment, babysitting, in-home sales, odd jobs.
Amount Before Taxes/Deductions
Person Working
Student
Employer/Source of Earnings
How Often Paid/Received
Yes
No
Yes
No
Yes
No
3. OTHER INCOME: Tell us about any other income your family has like Social Security, SSI, child support, Veteran’s Benefits, Unemployment
Compensation, pension, roomer, or cash given to you.
Person Paid To
Source of Money
How Often Paid
Amount Before Deductions
4. DEPENDENT CARE COSTS: Tell us how much you pay someone to care for a child or incapacitated adult so that you can go to work, look for work,
or get training.
Name of Child or Adult
Monthly Amount Paid
Name of Child or Adult
Monthly Amount Paid
5. HEALTH INSURANCE INFORMATION: Tell us about any health insurance you have.
Name of Policy Holder
Name of Insurance
Who is Covered
Circle What is Covered
Policy Number
Doctor Hospital Lab Tests Xray
Doctor Hospital Lab Tests Xray
Name anyone who has had health insurance in the last 6 months: _________________________________________________________________
Circle what the insurance covered: Doctor, Hospital, Lab Tests, X-rays
When did the insurance stop? __________________ Why did the insurance stop? _______________________________________________________
RIGHTS AND RESPONSIBILITIES
I have read or have had read to me all statements on this form and the
I understand that as a medical assistance recipient, I will automatically
information I give is true and complete to the best of my knowledge. I
receive full child support services from the Division of Child Support
understand that I could be penalized if I knowingly give false information.
Enforcement; unless I state that I want to receive only child support services
related to medical support.
I understand that all information I give is confidential and federal and state
laws limit disclosure of information about me.
I understand that if I am a Medicaid applicant or recipient I have the right to a
fair hearing if I am not satisfied with any decision made about my eligibility. I
I understand and agree to give proof of my statements. I understand and
understand that I may be represented by an attorney or any other person I
agree that the Department of Health and Social Services may contact other
choose.
persons or organizations to obtain the necessary proof of my eligibility.
I agree to allow Delaware Health and Social Services, directly or through its
I must give the Social Security Number for each person applying and it will be
agents or the Diamond State Health Plan or the Delaware Healthy Children
used to check records with other government agencies. The Division of
Program, to have access to all medical and school-based health and related
Medicaid & Medical Assistance (DMMA) also asks me to give the Social
services records of every member of my household who is eligible for
Security Number of anyone whose income is used to determine my eligibility.
Medical Assistance in order to administer the medical assistance program,
Nonlawful aliens are not required to give a Social Security Number.
coordinate care, determine medical necessity, and evaluate or pay for
pending or incurred medical services.
I understand that this application will be considered without regard to race,
color, sex, age, disability, religion, national origin, or political belief.
I certify, under penalty of perjury, that I am a U.S. Citizen or alien in lawful
immigration status. I must give proof of lawful immigration status and it will
I understand that I must apply for and accept other benefits that I may be
be checked with U.S. Citizenship and Immigration Services. Non-lawful alien
eligible to get such as Unemployment Compensation or Social Security.
status will not be checked. This will not affect any public charge
determination or lead to deportation proceedings. Certain aliens may be
I will allow Delaware Health and Social Services, or its representatives, to act
eligible for emergency services and labor and delivery only.
as my agent in recovering money spent by the medical assistance programs
when other money from insurance, etc., becomes available to pay my
I agree to report within 10 days changes in my situation that could affect my
medical bills.
eligibility, such as a change in how many people live with me, a new job or
change in income, or if I move.
I may have to repay to the DMMA any medical assistance received for which
I am not entitled. My obligation to repay such assistance applies both during
This application must be signed by an adult household member (age 18 or
my period of eligibility and after I am no longer receiving medical assistance.
over) or by an emancipated minor (under age 18).
As required by law as conditions of eligibility, I assign all rights to medical
support and to payment for medical care from any third party to the DMMA
___________________________________________
___________________
and I understand I must cooperate with the Division of Child Support
Signature of Applicant or Representative
Date
Enforcement in establishing paternity and obtaining medical support for any
child receiving medical assistance.
I understand that pregnant women are not required to cooperate in
___________________________________________ ____________________
Signature of DHSS Worker
Date
establishing paternity and obtaining medical support and that I may claim to
have good cause for refusing to cooperate in establishing paternity or in
identifying and providing information about liable third parties.
Form 403
Revised 02/2011
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