DC1000 DCO 151
User Manual: DC1000
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Arkansas Department of Human Services Application for Health Coverage Single Adults Use this application to see what coverage you qualify for through DHS. Medicaid, ARKids First or the Health Care Independence Program If you are not eligible for any of the above coverage, your information will be transferred to the Federally Facilitated Health Insurance Marketplace to determine your eligibility for tax credits to help pay for a Qualified Health Plan. Single adults who: Don’t have any dependents and can’t be claimed as a dependent on someone else’s tax return. Who can use this application? NOTE: If any of the following apply you will need to fill out form DCO-152 to make sure you get the most benefits possible: You’re married or have dependent children. You were in the Foster Care system and you’re under 26. You have items that can be deducted from your income. If your only deduction is student loan interest, you can use this form. You’re American Indian or Alaska Native. Apply faster online. Apply faster online at Access.Arkansas.gov. What you may need to apply. Why do we ask for this information? What happens next? We ask about income and other information to let you know what coverage you qualify for and if you can get help paying for it. We’ll keep all the information you provide private and secure as required by law. To view the Privacy Act Statement go to Access.Arkansas.gov. Send your completed, signed application to the address on Page 4. If you don’t have all the information we ask for, sign and submit your application anyway. Get help with this application. DCO-151 (10/13) Page 1 of 4 Your Social Security number (or document number if you’re a legal immigrant). Employer and income information (for example, from paystubs, W-2 forms, or wage and tax statements . Phone: Call our Help Center at 1-855-372-1084. In person: Contact your local DHS county office for more information. En Español: Llame a nuestro centro de ayuda gratis al 1-855-372-1084. Step 1 – Tell Us About Yourself 1. First name, Middle name, Last name & Suffix 2. Home address 3. Apartment or Suite number 4. City 5. State 6. Zip Code 8. Mailing address (if different from home address) 10. City 14. Phone number ( ) 7. County 9. Apartment or Suite number 11. State 12. Zip Code 13. County 15. Other phone number ( ) - - 16. Do you want to get information about this application by email? Yes No Email address: _____________________________________________________ 17. What is your preferred spoken or written language (if not English)? 18. Date of birth (mm/dd/yyyy) 19. Sex Male Female 20. Social Security number (SSN) ___ ___ ___-___ ___-___ ___ ___ ___ We need this if you want health coverage and have an SSN. We use SSNs to check income and other information to see if you’re eligible for help with health coverage costs. If you need help getting an SSN, call 1-800-772-1213 or visit socialsecurity.gov. TTY users should call 1-800-325-0778. 21. Are you a U.S. citizen or U.S. national? Yes No 22. If you aren’t a U.S. citizen or U.S. national: Do you have eligible immigration status? Yes. Fill in your document type and ID number below. a. Immigration document type_____________________________________ b. Document ID number __________________________________________ c. Have you lived in the in the U.S. since 1996? Yes No d. Are you a veteran or an active duty member of the U.S. Military? Yes No 23. Are you pregnant? Yes No If yes, how many babies are expected during this pregnancy? ____________________ 24. Do you have a physical, mental or emotional health condition that causes limitations in activities (like bathing, dressing, daily chores, etc.) or live in a medical facility or nursing home? Yes No 25. If Hispanic/Latino, ethnicity (OPTIONAL – Check all that apply.) Mexican Mexican American Chicano/a Puerto Rican 26. Race (OPTIONAL – Check all that apply.) White Guamanian or Chamorro Black or African American American Indian or Alaska Native Filipino Vietnamese Other Asian Samoan Cuban Other ____________ Japanese Korean Native Hawaiian Other _________________ NEED HELP WITH YOUR APPLICATION? Call us at 1-855-372-1084. Para obtenar una de este formulario en Español, llame 1-855-372-1084. If you need help in a language other than English, call 1-855-372-1084 and tell the Customer Service representative the language you need. We’ll get you help at no cost to you. DCO-151 (10/13) Page 2 of 4 Step 2 – Current Job & Income Information Employed If you’re currently employed, tell us about your income. Start with question 1. Not employed Skip to question 11. Self-employed Skip to question 10. CURRENT JOB 1: 1. Employer Name and Address 2. Employer Phone Number 3. Wages/tips (before taxes) $ ______________________________ Hourly Weekly Every 2 Weeks Twice a Month Monthly Yearly 4. Average hours worked each week: _____________________________ CURRENT JOB 2: 5. Employer Name and Address 6. Employer Phone Number 7. Wages/tips (before taxes) $ ______________________________ Hourly Weekly Every 2 Weeks Twice a Month Monthly Yearly 8. Average hours worked each week: _____________________________ 9. In the past year, did you: Change jobs? Stop working? None of these? Start working fewer hours? 10. If self-employed, answer the following questions: a. Type of work b. How much net income (profits once business expenses are paid) will you receive from this self-employment this month? _________________________________ $ ____________________________________ 11. OTHER INCOME THIS MONTH: Check all that apply and give the amount and how often you receive that amount. NOTE: You don’t need to tell us about child support, veteran’s payments or Supplemental Security Income (SSI). None Retirement Accounts $ _______ How often? _________ Unemployment $ _____ How often? ___________ Alimony received $ _______ How often?_________ Pensions $ _____ How often? ___________ Net farming/fishing $ _______ How often?_________ Social Security $ _____ How often? ___________ Net rental/royalty $ _______ How often? ________ Other income $ _____ How often? ___________ Other type:________________________________________ 12. Do you pay student loan interest (not the amount of the loan) that can be deducted on a federal income tax return? Yes No If yes, how much? ___________________ How often? ___________________________ 13. YEARLY INCOME: Complete only if your income changes from month to month. If you don’t expect changes in your monthly income, skip to Step 3. Your total income this year: Your total income next year (if you think it will be different): $ $ Step 3 – Your Health Coverage Are you enrolled in health coverage now from any of the following? Yes No If yes, check which coverage you have: Medicaid (from another state) VA Health Care programs CHIP (from another state) Other Medicare Name of Health insurance: TRICARE (Don’t check if you have Direct Care or Line of Duty) ________________________________________ Peace Corps Policy Number:_______________________________ DCO-151 (10/13) Page 3 of 4 Step 4 – Read & Sign This Application I’m signing this application under penalty of perjury, which means I’ve provided true answers to all the questions on this form to the best of my knowledge. I know that I may be subject to penalties under the federal law if I intentionally provide false or untrue information. I know that I must tell the Department of Human Services if anything changes (and is different than) what I wrote on this application. I can visit Access.Arkansas.gov or call 1-855-372-1084 to report any changes. I understand that a change in my information could affect my eligibility. I know that under federal law, discrimination isn’t permitted on the basis of race, color, national origin, sex, age, sexual orientation, gender identity or disability. I can file a complaint of discrimination by calling 1-501-682-6003. I confirm that I’m not incarcerated (detained or jailed). I confirm that next year I expect to file a federal income tax return, won’t claim dependents on that return and can’t be claimed as a dependent on anyone else’s federal income tax return. I understand that the Health Care Independence Program is not a federal or state entitlement program and that it may be ended at any time upon appropriate notice. We need this information to check your eligibility for Medicaid, ARKids First or the Health Care Independence Program if you choose to apply. We’ll check your answers using information in our electronic databases and databases from the Internal Revenue Service (IRS), Social Security, the Department of Homeland Security, and/or a consumer reporting agency. If the information doesn’t match, we may ask you to send us proof. Renewal of Coverage in Future Years To make it easier to determine my eligibility for Medicaid, ARKids First or the Health Care Independence Program coverage in future years, I agree to allow the Department of Human Services to use income data including information from tax returns. DHS will send me a notice, allow me to make any changes and I can opt out at any time. Yes, renew my eligibility automatically for the next: 5 years (the maximum number of years allowed) Or for a shorter number of years: 4 years 3 years 2 years 1 years Don’t use tax return information to renew coverage If I’m eligible: If I enroll in Medicaid, ARKids First or the Health Care Independence Program, I’m giving the Department of Human Services my rights to pursue and get money from other health insurance, legal settlements or other third parties. My right to appeal: If I think DHS has made a mistake, I can appeal its decision. To appeal means to tell someone at the Department of Human Services that I think the action is wrong and ask for a fair review of the action. I know I can find out how to appeal an action by contacting DHS at 1-501-682-8622. I know that I can be represented in the process by someone other than myself. My eligibility and other important information will be explained to me. Sign this application: The person who filled out Step 1 should sign this application. If you’re an Authorized Representative, you may sign here as long as you have provided a signed copy of the DCO-153, Consent for an Authorized Representative. Signature Date (mm/dd/yyyy) Step 5 – Submit Completed Application Mail your signed application to: DHS Jefferson County Or email your signed application to: 351Jefferson@arkansas.gov th 1222 West 6 Street P.O. Box 5670 Or FAX your signed application to: 1-870-534-3421 Pine Bluff, AR 71611 What happens next? We will process your application for Medicaid, ARKids First or the Health Care Independence Program and send you a notice to tell you if your application has been approved or denied and provide instructions on the next steps needed to complete your health coverage. If you are not eligible for any of these programs, we will screen your application for potential eligibility for tax credits to help you pay for health insurance premiums and then transfer your information to the Health Insurance Marketplace. We will provide instructions on how to complete the application process on the notice we send you. If you want to register to vote, complete the Voter Registration packet that was given to you as a part of this application packet. DCO-151 (10/13) Page 4 of 4
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