Form CF-es 2282 "Medicaid/Medicare Buy-In Application" - Florida

What Is Form CF-es 2282?

This is a legal form that was released by the Florida Department of Children and Families - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on July 1, 2006;
  • The latest edition provided by the Florida Department of Children and Families;
  • 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 CF-es 2282 by clicking the link below or browse more documents and templates provided by the Florida Department of Children and Families.

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Download Form CF-es 2282 "Medicaid/Medicare Buy-In Application" - Florida

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MEDICAID/MEDICARE BUY-IN APPLICATION
Page 1
Demographic Information:
Please complete all information for you and your spouse. If no spouse, indicate “None”.
Your Name (Applicant):
First
MI
Last
Your Social Security Number:
Sex:
Male
Female
Name of Spouse:
First
MI
Last
Spouse’s Social Security Number (if applying):
Sex:
Male
Female
Do you and your spouse live together?
Yes
No
Your Medicare claim number:
Spouse’s Medicare # (if applying):
Living Address:
______________________________________________________________________________________________
Number
Street
Apt #
City
Zip Code
Mailing Address: ______________________________________________________________________________________________
Number
Street
Apt #
City
Zip Code
Telephone Number:
Telephone #
Contact Person: __________________________________________________________________________
(Other than Yourself)
First
Last
MI
______________________________________________________________________________________________
Number
Street
Apt #
City
Zip Code
___________________________________
Telephone #
Date Stamp: (Official DCF use only)
Relationship of Contact Person to you:___________________________________________
Do you want eligibility determined for the
three months before the month of application?
Yes
No
Technical Information:
Please complete all information for you and your spouse.
Date of Birth:
________________
________________
You
Spouse
Are you a U.S. Citizen?
You:
Spouse:
Yes
No
Yes
No
If not a citizen, provide alien number and status: __________________________________ ; __________________________________
You
Spouse (if applying)
Do you intend to remain in the State of Florida?
You:
Spouse:
Yes
No
Yes
No
Do you and/or spouse have any other insurance other than Medicare?
You:
Spouse:
If Yes, Complete the following information:
Yes
No
Yes
No
______________________________________________________________________________________________________________
Name of Other Insurance Company
Other Insurance Policy Number
______________________________________________________________________________________________________________
Address of Other Insurance Company
Who is Covered by This Insurance
CF-ES 2282, PDF 07/2006
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MEDICAID/MEDICARE BUY-IN APPLICATION
Page 1
Demographic Information:
Please complete all information for you and your spouse. If no spouse, indicate “None”.
Your Name (Applicant):
First
MI
Last
Your Social Security Number:
Sex:
Male
Female
Name of Spouse:
First
MI
Last
Spouse’s Social Security Number (if applying):
Sex:
Male
Female
Do you and your spouse live together?
Yes
No
Your Medicare claim number:
Spouse’s Medicare # (if applying):
Living Address:
______________________________________________________________________________________________
Number
Street
Apt #
City
Zip Code
Mailing Address: ______________________________________________________________________________________________
Number
Street
Apt #
City
Zip Code
Telephone Number:
Telephone #
Contact Person: __________________________________________________________________________
(Other than Yourself)
First
Last
MI
______________________________________________________________________________________________
Number
Street
Apt #
City
Zip Code
___________________________________
Telephone #
Date Stamp: (Official DCF use only)
Relationship of Contact Person to you:___________________________________________
Do you want eligibility determined for the
three months before the month of application?
Yes
No
Technical Information:
Please complete all information for you and your spouse.
Date of Birth:
________________
________________
You
Spouse
Are you a U.S. Citizen?
You:
Spouse:
Yes
No
Yes
No
If not a citizen, provide alien number and status: __________________________________ ; __________________________________
You
Spouse (if applying)
Do you intend to remain in the State of Florida?
You:
Spouse:
Yes
No
Yes
No
Do you and/or spouse have any other insurance other than Medicare?
You:
Spouse:
If Yes, Complete the following information:
Yes
No
Yes
No
______________________________________________________________________________________________________________
Name of Other Insurance Company
Other Insurance Policy Number
______________________________________________________________________________________________________________
Address of Other Insurance Company
Who is Covered by This Insurance
CF-ES 2282, PDF 07/2006
BUY-IN APPLICATION
Page 2
Asset Information:
Please list all assets owned by you and/or spouse (even if your spouse is not applying).
NAME OF BANK/
VALUE OF
IN WHOSE NAME
TYPE
ADDRESS
ACCOUNT NUMBER
FINANCIAL INSTITUTION
ASSET
IS IT HELD
CASH
SAVINGS ACCOUNT
CHECKING ACCOUNT
CAR
Make/Model/Year:
HOMESTEAD
OTHER PROPERTY
TRUST FUND
STOCKS/BONDS
TAX SHELTERED
ACCOUNTS
LIFE INSURANCE
KEOGH PLAN
Other: Please Specify
Income Information:
Please complete all information for you and your spouse (even if spouse is not applying).
Are you or your spouse self-employed?
Applicant
Spouse
Yes
No
Gross Amount
Yes
No
Gross Amount
Earned Monthly
Earned Monthly
Do you or your spouse work for someone else?
Applicant
Spouse
Yes
No
Gross Amount
Yes
No
Gross Amount
Earned Monthly
Earned Monthly
D
o you or your spouse receive income from any of the following?
Gross Amount Received Each Month
(Before Any Deductions)
Type
Benefit No.
Applicant
Spouse
Veterans Benefits
Pension
Interest/Dividends
Civil Service Annuity
Income from another person
Black Lung
Social Security
Other (e.g. SSI, Annuities): (specify)
CF-ES 2282, PDF 07/2006
BUY-IN APPLICATION
Page 3
YOUR RIGHTS AND RESPONSIBILITIES:
Read this sheet before you sign your name.
YOU HAVE THE RIGHT TO:
Apply for assistance and have a determination of your eligibility made without regard to race, color, sex, age, handicap, religion,
national origin, marital status or political belief.
Have a representative help you fill out the eligibility forms.
Have action taken on your application promptly and be notified of such action.
Be informed of other available services of the Department of Children and Families.
Request a fair hearing when you disagree with a decision of the Department of Children and Families.
Have the information about you and/or your spouse that is collected by the department treated confidentially in accordance with
federal and state laws.
YOU HAVE THE RESPONSIBILITY TO (things you must do):
Assist in determining your eligibility by giving complete and correct information and provide written proof of information, as
requested, within the time limits given.
Declare the citizenship or alien status for you and your spouse by signing the Medicaid/Medicare Buy-In Application.
File for any payments or benefits from other sources if this application, or other information, indicates that you or your spouse may
be eligible for such payments or benefits.
Assign your rights to third party benefits and cooperate in reporting any insurance or other health plan that covers medical costs
for you (and/or your spouse, if applying) unless good cause can be shown not to do so.
Report changes in your situation (e.g., income, assets) within 10 days of the change.
Report your (and your spouse’s, if applying) Social Security numbers. Without accurate numbers, we will be unable to provide
Medicaid/Medicare buy-in benefits if you are determined eligible for any benefits.
IMPORTANT INFORMATION ABOUT MEDICAID:
Any person (including the designated representative) who knowingly withholds information or knowingly misrepresents the truth may be
punished under federal or state law or both. If you get medical assistance for which you do not qualify, you may have to repay the cash
value of that assistance.
Certification of Citizenship/Alien Status:
I certify, under the penalty of perjury, by signing my name on this application, that I and
my spouse (if applicable) are U.S. citizens or nationals of the United States or qualified aliens.
Certification:
In signing this application, I swear and affirm, under penalty of perjury, that the information I have given on this application
is correct and complete to the best of my knowledge. I have read and understand the above rights and responsibilities and important
information about Medicaid.
Go Back To Page 1
Applicant
Signature:
Date:
Spouse
Signature:
Date:
Designated
Representative Signature:
Date:
HELPING PERSON: (Official use only)
Date:
Signature of Individual Who Assisted Applicant in Completing Buy-In Application Form
In accordance with Federal law and our policy, the Department of Children and Families is
prohibited from discriminating on the basis of race, color, national origin, sex, age, disability,
religion, political belief, or marital status.
CF-ES 2282, PDF 07/2006
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