Form DMA-5063 "Health Check (Medicaid) Nc Health Choice for Children Application" - North Carolina

What Is Form DMA-5063?

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

Form Details:

  • Released on February 1, 2012;
  • The latest edition provided by the North Carolina Department of Health and Human 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 DMA-5063 by clicking the link below or browse more documents and templates provided by the North Carolina Department of Health and Human Services.

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Download Form DMA-5063 "Health Check (Medicaid) Nc Health Choice for Children Application" - North Carolina

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HEALTH CHECK (MEDICAID)
NC HEALTH CHOICE FOR CHILDREN APPLICATION
Free or Low-Cost Health Coverage
This application may also be used by parents, caretakers, pregnant women & other adults to apply for Medicaid.
Si usted desea obtener la forma DMA-5063, solicitud en español para seguro medico para niños,
comuníquese con el departamento de servicios sociales de su localidad. También puede llamar al Centro de
Atención al Cliente del Departamento de Salud y Servicios Humanos (DHHS, por sus siglas en inglés) al
1-800-662-7030. Se le atenderá en español. (You can get a Spanish application at your local department of
social services or call 1-800-662-7030.)
WHAT ARE HEALTH CHECK (MEDICAID) & NC HEALTH CHOICE FOR CHILDREN?
Health Check (Medicaid) and Health Choice are two similar health coverage programs. Your family’s
income, the number of people in your family and the age of the children determine if you or your children
qualify. This information will also be used to determine in which program the children will be enrolled.
WHAT ARE THE BENEFITS?
Sick visits
Counseling
Eye exams and glasses
Checkups
Prescriptions
Hearing exams and hearing aids
Hospital care
Dental Care
And more!
Transportation - Medical transportation may be available to individuals authorized and receiving Health Check
(Medicaid). If you need assistance with transportation to receive medical care, contact your local department
of social services after you receive a letter approving Health Check (Medicaid). If the children are enrolled in
Health Choice, you must provide your own transportation.
HOW DO I APPLY?
It's easy. Just mail or drop off the completed application at the department of social services in the
county where you live. If you would like help filling out the application, call or visit your department of social
services. You can find the address and phone number in your phone book under “County Government” or by
calling the DHHS Customer Service Center at 1-800-662-7030.
Be careful to answer all the questions completely so we can process your application more quickly.
If you need more space, please attach additional pages. It can take 45 days or less to process your
application. If we need additional information, we will contact you by mail. The sooner we get the
information, the sooner we can let you know if you or your children qualify.
WHO CAN ANSWER MY QUESTIONS?
Contact the department of social services in the county where you live or call the DHHS Customer Service
Center at 1-800-662-7030.
DMA-5063 (02-2012)
Questions about Health Check/ Health Choice? Call 1-800-662-7030.
Page 1
HEALTH CHECK (MEDICAID)
NC HEALTH CHOICE FOR CHILDREN APPLICATION
Free or Low-Cost Health Coverage
This application may also be used by parents, caretakers, pregnant women & other adults to apply for Medicaid.
Si usted desea obtener la forma DMA-5063, solicitud en español para seguro medico para niños,
comuníquese con el departamento de servicios sociales de su localidad. También puede llamar al Centro de
Atención al Cliente del Departamento de Salud y Servicios Humanos (DHHS, por sus siglas en inglés) al
1-800-662-7030. Se le atenderá en español. (You can get a Spanish application at your local department of
social services or call 1-800-662-7030.)
WHAT ARE HEALTH CHECK (MEDICAID) & NC HEALTH CHOICE FOR CHILDREN?
Health Check (Medicaid) and Health Choice are two similar health coverage programs. Your family’s
income, the number of people in your family and the age of the children determine if you or your children
qualify. This information will also be used to determine in which program the children will be enrolled.
WHAT ARE THE BENEFITS?
Sick visits
Counseling
Eye exams and glasses
Checkups
Prescriptions
Hearing exams and hearing aids
Hospital care
Dental Care
And more!
Transportation - Medical transportation may be available to individuals authorized and receiving Health Check
(Medicaid). If you need assistance with transportation to receive medical care, contact your local department
of social services after you receive a letter approving Health Check (Medicaid). If the children are enrolled in
Health Choice, you must provide your own transportation.
HOW DO I APPLY?
It's easy. Just mail or drop off the completed application at the department of social services in the
county where you live. If you would like help filling out the application, call or visit your department of social
services. You can find the address and phone number in your phone book under “County Government” or by
calling the DHHS Customer Service Center at 1-800-662-7030.
Be careful to answer all the questions completely so we can process your application more quickly.
If you need more space, please attach additional pages. It can take 45 days or less to process your
application. If we need additional information, we will contact you by mail. The sooner we get the
information, the sooner we can let you know if you or your children qualify.
WHO CAN ANSWER MY QUESTIONS?
Contact the department of social services in the county where you live or call the DHHS Customer Service
Center at 1-800-662-7030.
DMA-5063 (02-2012)
Questions about Health Check/ Health Choice? Call 1-800-662-7030.
Page 1
WHAT ELSE DO I NEED TO KNOW ABOUT HEALTH CHECK & HEALTH CHOICE?
Will I Be Enrolled Immediately?
Health Check (Medicaid) has no funding limits, so there is no waiting list. If your children are eligible for Health Choice,
they may have to go on a waiting list before being enrolled if federal or state funds are not sufficient to serve more
children.
Will I Get Identification Cards?
YES! You will receive identification cards in the mail. Please keep the card handy so you can show it at medical
appointments and when you fill prescriptions.
How Do I Choose a Doctor?
The department of social services will help you choose your doctor.
Will I Have to Pay Enrollment Fees and Co-pays?
Depending on your income, you may have to pay an enrollment fee of $50 to $100 per family per year. In some cases,
you also may have a small co-pay for doctor visits and prescriptions. If the fee and/or co-pay apply to you, you will be
notified.
Will I Need to Re-enroll?
YES! You will need to re-enroll to continue benefits. For most children this is done once a year. You will be contacted
when it is time to re-enroll.
WHAT ARE MY RESPONSIBILITIES?
You agree to tell the department of social services within 10 days if there are any changes in the information you
provided on your application.
A state or federal reviewer may check the information on this form. You agree to participate in the review and will
cooperate with the reviewer.
If you knowingly provide false information or if you withhold information and you or your children get health
coverage for which they are not eligible, you can be lawfully punished for fraud and may be asked to repay the
programs for any medical bills and/or premiums that were paid incorrectly.
If Health Check (Medicaid)/Health Choice pays for health care for you or your children, you give permission to the
state of North Carolina to collect payments from anyone who is supposed to pay for that care. You also agree to
share medical information about your children with any insurance company to get the medical bills paid.
You agree to tell the department of social services if anyone with Health Check (Medicaid) is in an accident.
For a person to be enrolled in Health Check (Medicaid)/Health Choice, you must provide his/her social security
number or apply for a number. These numbers will be matched by computer with other government agency records
(but not the Bureau of Citizenship and Immigration Services) to verify information. If you decide not to give the
numbers, the person cannot be enrolled.
For a person to be enrolled in Health Check (Medicaid)/Health Choice, you must provide proof of identity and U.S.
citizenship or information for the county DSS to obtain the proof for those applying for benefits. For refugees and
legally qualified immigrants, provide proof of legal status for those applying.
WHAT ARE MY RIGHTS?
Health Check (Medicaid)/Health Choice cannot discriminate on the basis of race, color, nationality, sex, religion, age,
or disability in employment or the provision of services.
By law, all information that you provide remains private.
You can ask for a hearing if you think any decisions are unfair, incorrect or are made too late. You have the right to
have an attorney or other legal representative represent you at the hearing. Free legal aid may be available. Call 1-
866-219-5262 for more information.
REPORTING FRAUD/ABUSE
To report fraud, waste or program abuse, please contact the DHHS Customer Service Center at 1-800-662-7030.
Before you return the application, please make sure to do the following:
Read pages 1 and 2. Tear them off and keep for your records.
Complete the questions on pages 3 through 6.
Sign the application on page 6.
DMA-5063 (02-2012)
Questions about Health Check/ Health Choice? Call 1-800-662-7030.
Page 2
For Office Use Only
County DSS: _____________________
Date Received: ___________________
Case #: __________________________
Mail in
DSS
Health Dept
APPLICATION
Please complete. Then send pages 3-6 to your local department of social services. If you are an adult who has
no children living with you and you are applying for Medicaid, Medicaid for Pregnant Women or Family Planning
Services, begin with Question #2.
Tell Us About the Family
1. Who are all the children under age 21 who live in the home?
Fill out this information even for children who will not be applying for Health Check (Medicaid)/Health Choice. Social
Security number, proof of identity, and citizenship status are required only for those applying.
*Race
**Hispanic/Latino
Applying
(Use
Is Child
Date of
(Y, N)
Social Security
Name of child
for this
Sex
codes
a U.S.
birth
If yes, specify
Number
(first, middle initial, last)
child
(M, F)
below.
citizen?
(mo/day/yr)
using codes
(SSN)
(Y, N)
List all that
(Y, N)
below.
apply.)
*Asian= A American Indian or Alaska Native= I
Native Hawaiian or other Pacific Islander= P Caucasian or White= W
Black or African-American= B
** Hispanic Puerto Rican= P
Hispanic Cuban= C
Hispanic Mexican= M
Hispanic Other= H
2. Where do you & the children live?
(If different, please put your address on a separate sheet and return
with this application.)
Address:
Mailing Address (if different):
City:
State:
Zip Code:
City:
State:
Zip Code:
Home phone: (
)
Daytime phone: (
)
3. Who are the parents living with the children? If the children do not live with their parents, who are the adults
living in the home who care for the children?
**Hispanic/
*Race (Use
Latino
Children’s names and parent or adult
Name of parent or adult
Date of birth
Sex
codes in
(Y, N)
relationship to the children
(first, middle initial, last)
(mo/day/yr)
(M, F)
#1. List all
If yes, specify
(John – Mother, Mary - Stepmother)
that apply.)
using codes in
#1.
Anyone who applies for Medicaid, Medicaid for Pregnant Women, or Family Planning Services must provide their Social
Security numbers and may have to give information to the child support office
a. Do you want to apply for pregnancy coverage for any of the people listed in #3 above?
Yes
No
If you are applying for pregnancy assistance, you need to provide a statement from the doctor that includes the delivery
date and the number of babies expected. However, send in the application form even if you do not have the statement
from the doctor yet.
If yes, for whom?
Relationship to child(ren):
SSN
b. Do you want to apply for Medicaid for any of the people listed in #3 above? If you want to apply, you will be
contacted for information about bank accounts, personal property, stocks, bonds, etc. The total of these must be
less than $3,000. Also, if eligible, the person may be responsible for some medical bills.
Yes
No
If yes, for whom?
Relationship to child(ren):
SSN
c. Do you want to apply for family planning services for any people ages 19 and older listed above?
Yes
No
If yes, for whom?
Relationship to child(ren):
SSN
DMA-5063 (02-2012)
Questions about Health Check/ Health Choice? Call 1-800-662-7030.
Page 3
4. Is there a family member living away from the home for less than 12 months (Example: military service,
attending school)?
Yes
No
If yes, please give information below:
Relationship to
Full name (first, middle initial, last)
Reason for absence
Expected date of return
child(ren)
Tell Us About the Family’s Health Insurance and Medical Needs
5. Is there currently a parent not living in the home?
Yes
No
If yes, what is that parent’s name? (optional)
Is that parent required by an agreement to pay for health insurance?
Yes
No
6. Does anyone applying have other health plan/coverage?
Yes
No
If yes, please give information below:
Name of Insured
Insurance
Insurance Company
Insurance Company
Group/Policy
Owner of Policy
(first, middle initial, last)
Company Name
Address
Phone Number
Number
7. Does anyone applying need help paying medical bills from the past three months?
Yes
No
If yes, please give the information below: We may be able to help pay those bills.
Name of person(s) with bill
Name of doctor, clinic and/or hospital where person was
Date of medical treatment
(first, middle initial, last)
treated
8. Has anyone applying been in an accident in the past 12 months?
Yes
No
Did he/she receive medical care because of the accident?
Yes
No
If yes, please tell us who.
When was the accident?
Tell Us About the Parent’s and Children’s Income
9. Who are the parents and children in the home who work and what are their wages?
Amount
How often paid
Name of working person
Tips
Employer's name and phone number
earned before
(monthly, weekly,
(first, middle initial, last)
earned
deductions
etc.)
Please provide copies of all of last month’s paycheck stubs for everybody listed. Send in the application even if you do
not have your stubs.
DMA-5063 (02-2012)
Questions about Health Check/ Health Choice? Call 1-800-662-7030.
Page 4
10. Is there anyone in the home who is self-employed?
Yes
No
For example, does anyone earn money from farming, own his or her own business, or have rental property income?
If yes, please attach business records showing income and expenses for the last 6 months or the number of months in
business if less than 6 months. If the income is annual, please attach business records for the last 12 months.
11. Has anyone in the home lost a job in the past three months?
Yes
No
If yes, please complete the following:
Name of person(s) who lost
Former employer's address & phone
Date job lost
Former employer’s name
a job
number
12. If the parent or child receives income from any other source please complete the blocks below.
How often received
Type of income
Name of the person who receives other income
Amount received
(monthly, weekly,
etc.)
$
Child Support:
$
Social Security:
$
Unemployment:
Other (Please explain):
$
Tell Us About the Parent’s and Children’s Expenses
Some of these expenses may be used to reduce the income that we count to determine enrollment in Health Check
(Medicaid)/Health Choice.
13. Does a working parent living in the home pay for childcare, a babysitter or care for a dependent adult?
Yes
No
If yes, please fill in the information:
Name, address & phone number of
Name of person
Name of person paying
Amount paid
How often paid
sitter or care provider
cared for
for care
(monthly, weekly,
etc.)
14. Does a parent living in the home pay child support for a child who is not living in the home?
Yes
No
If yes, please fill in the information.
How often paid
Amount paid
Who pays the support & to
Is it court
For whom is the support paid
(monthly, weekly,
Please Attach
whom
ordered? (Y, N)
Verification
etc.)
$
$
$
DMA-5063 (02-2012)
Questions about Health Check/ Health Choice? Call 1-800-662-7030.
Page 5
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