Application for Oregon Health Plan and Healthy Kids
Read this before you start. You can get this application in other formats. • This is for the Oregon Health Plan and Healthy Kids. You • This document can be provided upon request in alternative can apply for one or both programs with this application. formats for individuals with disabilities. Other formats may • Please answer all questions so we have the information include (but are not limited to) large print, Braille, audio we need to see if you qualify. recordings, Web-based communications and other electronic formats. Email [email protected], or call • Read the Green Booklet by clicking here. 1-800-699-9075 (voice) or TTY 711 to arrange for the It includes more information about the questions asked. alternative format that will work best for you. When you see this arrow, it means you may have to • You can get this application in another language or you send documents that show us the information you gave can get an interpreter. Call 1-800-699-9075 or TTY 711. is correct. Please mail copies of these documents along with your application to: For more information about: OHP Processing Center, • Healthy Kids or to find local application assistance, PO Box 14520, Salem, OR 97309-5044 click here: www.oregonhealthykids.gov or fax to 503-373-7493 • Oregon Health Plan, click here: www.oregon.gov/OHA/healthplan
1 About you. Please tell us about yourself, even if you are only applying for benefits for your children. You may need to send proof of immigration status or tribal affiliation if you are applying for yourself (see the checklist on page 16). Name (first, middle initial, last) Sex female OHP Drawing entry number (if you male have one) Phone (required) Email
Home address Apartment # City (home address) State ZIP code (required)
Mailing address (if not your home address) Apartment # City (mailing address) State ZIP code (required)
Date of birth (month, day, year) City of birth State of birth Maiden or birth name
Are you applying for health coverage for yourself? Your answers to these questions help us, but you can choose not to answer. Yes No If yes, you must tell us about Ethnicity Hispanic/Latino Not Hispanic/Latino citizenship and Social Security or immigration status: Race (choose one or more) Are you a U.S. citizen? Yes No If no, and you American Indian or Alaska Native Asian Black or African American have an Alien Resident number, write it here: Native Hawaiian or other Pacific Islander White Are you an Alaska Native or a member of a federally recognized Social Security number: If you do not have a American Indian tribe? Yes No Social Security number, Do you receive services through Indian Health Services or could you? check this box: Yes No
This section is for the office. Please continue the application on the next page.
For date stamp code only Received Program Branch Case # Worker ID
Case name Route to
Prime # SSN App status
Date of request Office use 2 People who live in your home. Please tell us about everyone (other than the person listed in Question 1) in your home. See the Green Booklet for more information. You may need to send proof of immigration status or tribal affiliation for each person applying for benefits (see the checklist on page 16).
Person 1 Name (first, middle initial, last) Are you applying for health coverage for Sex female this person? Yes No male
City of birth State of birth Date of birth (month, day, year) Maiden or birth name
This is my husband or wife child Your answers to these questions help us, but you can choose stepchild other: not to answer. Ethnicity Hispanic/Latino Not Hispanic/Latino If you are applying for this person, you must tell us about Race (choose one or more) American Indian or Alaska Native citizenship and Social Security: Asian Black or African American Is this person a U.S. citizen? Yes No Native Hawaiian or other Pacific Islander White If no, and this person has an Alien Resident number, write it here: Is this person an Alaska Native or a member of a federally recognized American Indian tribe? Yes No Social Security number: If this person does not have a Social Security number, Does this person receive services through Indian Health Services check this box: now or could this person receive services? Yes No
Person 2 Name (first, middle initial, last) Are you applying for health coverage for Sex female this person? Yes No male
City of birth State of birth Date of birth (month, day, year) Maiden or birth name
This is my husband or wife child Your answers to these questions help us, but you can choose stepchild other: not to answer. If you are applying for this person, you must tell us about Ethnicity Hispanic/Latino Not Hispanic/Latino citizenship and Social Security: Race (choose one or more) American Indian or Alaska Native Asian Black or African American Is this person a U.S. citizen? Yes No Native Hawaiian or other Pacific Islander White If no, and this person has an Alien Resident number, write it here: Is this person an Alaska Native or a member of a federally recognized American Indian tribe? Yes No Social Security number: If this person does not have a Social Security number, Does this person receive services through Indian Health Services check this box: now or could this person receive services? Yes No
Person 3 Name (first, middle initial, last) Are you applying for health coverage for Sex female this person? Yes No male
City of birth State of birth Date of birth (month, day, year) Maiden or birth name
This is my husband or wife child Your answers to these questions help us, but you can choose stepchild other: not to answer. Ethnicity Hispanic/Latino Not Hispanic/Latino If you are applying for this person, you must tell us about Race (choose one or more) American Indian or Alaska Native citizenship and Social Security: Asian Black or African American Is this person a U.S. citizen? Yes No Native Hawaiian or other Pacific Islander White If no, and this person has an Alien Resident number, write it here: Is this person an Alaska Native or a member of a federally recognized American Indian tribe? Yes No Social Security number: If this person does not have a Social Security number, Does this person receive services through Indian Health Services check this box: now or could this person receive services? Yes No
Need help? Please call 1-800-699-9075 (TTY 711). Monday to Friday 7 a.m. to 6 p.m. page ? 2 OHA 7210W (Rev 6/12) 2 People who live in your home (continued). Please tell us about everyone (other than the person listed in Question 1) in your home. See the Green Booklet for more information. You may need to send proof of immigration status or tribal affiliation for each person applying for benefits (see the checklist on page 16).
Person 4 Name (first, middle initial, last) Are you applying for health coverage for Sex female this person? Yes No male
City of birth State of birth Date of birth (month, day, year) Maiden or birth name
This is my husband or wife child Your answers to these questions help us, but you can choose stepchild other: not to answer. If you are applying for this person, you must tell us about Ethnicity Hispanic/Latino Not Hispanic/Latino citizenship and Social Security: Race (choose one or more) American Indian or Alaska Native Asian Black or African American Is this person a U.S. citizen? Yes No Native Hawaiian or other Pacific Islander White If no, and this person has an Alien Resident number, write it here: Is this person an Alaska Native or a member of a federally recognized American Indian tribe? Yes No Social Security number: If this person does not have a Social Security number, Does this person receive services through Indian Health Services check this box: now or could this person receive services? Yes No
Person 5 Name (first, middle initial, last) Are you applying for health coverage for Sex female this person? Yes No male
City of birth State of birth Date of birth (month, day, year) Maiden or birth name
This is my husband or wife child Your answers to these questions help us, but you can choose stepchild other: not to answer. If you are applying for this person, you must tell us about Ethnicity Hispanic/Latino Not Hispanic/Latino citizenship and Social Security: Race (choose one or more) American Indian or Alaska Native Asian Black or African American Is this person a U.S. citizen? Yes No Native Hawaiian or other Pacific Islander White If no, and this person has an Alien Resident number, write it here: Is this person an Alaska Native or a member of a federally recognized American Indian tribe? Yes No Social Security number: If this person does not have a Social Security number, Does this person receive services through Indian Health Services check this box: now or could this person receive services? Yes No
Person 6 Name (first, middle initial, last) Are you applying for health coverage for Sex female this person? Yes No male
City of birth State of birth Date of birth (month, day, year) Maiden or birth name
This is my husband or wife child Your answers to these questions help us, but you can choose stepchild other: not to answer. Ethnicity Hispanic/Latino Not Hispanic/Latino If you are applying for this person, you must tell us about Race (choose one or more) American Indian or Alaska Native citizenship and Social Security: Asian Black or African American Is this person a U.S. citizen? Yes No Native Hawaiian or other Pacific Islander White If no, and this person has an Alien Resident number, write it here: Is this person an Alaska Native or a member of a federally recognized American Indian tribe? Yes No Social Security number: If this person does not have a Social Security number, Does this person receive services through Indian Health Services check this box: now or could this person receive services? Yes No
Use Extra Form A on page 9 if you need to tell us about more than 6 other people in your home.
Need help? Please call 1-800-699-9075 (TTY 711). Monday to Friday 7 a.m. to 6 p.m. page ? 3 OHA 7210W (Rev 6/12) 3 Pregnancy. Please tell us about anyone in your home (related to you or your children) who is pregnant. You must send proof. Please send a copy of a letter from a doctor or clinic saying this person is pregnant. Person 1 Name Due date (month, day, year) Does the baby’s father live in your home? Yes No What is his name?
Person 2 Name Due date (month, day, year) Does the baby’s father live in your home? Yes No What is his name? Use the space on page 15 if you need to tell us about more people who are pregnant.
4 Does your partner or spouse make you afraid by yelling or physically hurting you or your children? Yes No See page 13 of the Green Booklet for more information.
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.
Person 1 Name School name Does the school consider this student full time part time
Person 2 Name School name Does the school consider this student full time part time
Person 3 Name School name Does the school consider this student full time part time Use the space on page 15 if you need to write about more people who are in school. 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. Use Extra Form B on page 10 if you need to write about more than 2 absent parents.
Absent parent 1 Name (first, middle initial, last) This is my spouse or ex-spouse partner or ex-partner child stepchild other: Sex female Address City State ZIP code male Date of birth (month, day, year) Social Security number (if you know it) Date this parent stopped living with the child (month, day, year)
List this parent’s children if you have Hours each week this parent spends If this is an absent father, has paternity been legally included those children on this application. with the child: established? Yes No I don’t know Can the child or children get health Do you think this parent might hurt you or the insurance through this parent? child if we try to find out about paternity or Yes No I don’t know health insurance? Yes No
Absent parent 2 Name (first, middle initial, last) This is my spouse or ex-spouse partner or ex-partner child stepchild other: Sex female Address City State ZIP code male Date of birth (month, day, year) Social Security number (if you know it) Date this parent stopped living with the child (month, day, year)
List this parent’s children if you have Hours each week this parent spends If this is an absent father, has paternity been legally included those children on this application. with the child: established? Yes No I don’t know Can the child or children get health Do you think this parent might hurt you or the insurance through this parent? child if we try to find out about paternity or Yes No I don’t know health insurance? Yes No
Need help? Please call 1-800-699-9075 (TTY 711). Monday to Friday 7 a.m. to 6 p.m. page ? 4 OHA 7210W (Rev 6/12) 7 Money from work. 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 paystub received within the last 30 days, for each job listed. Does anyone in your home get money for working? Yes No If yes, fill out this page. 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, write about self-employment on Extra Form C on page 11.
Write the name of this month:
Write about the month that includes the day on which you are applying. For example, if you are applying on September 30th, write about September. Or, if you are applying on October 1st, write about October. Use your best guess for what the totals will be.
Job 1 Who earns money from this job? What person, business, or agency pays this person? This job pays: every week every 2 weeks every month
Does this job pay hourly? Yes No How many hours each week? How much gross income will this job If yes, how much each hour? $ pay this month? $
Job 2 Who earns money from this job? What person, business, or agency pays this person? This job pays: every week every 2 weeks every month
Does this job pay hourly? Yes No How many hours each week? How much gross income will this job If yes, how much each hour? $ pay this month? $
Job 3 Who earns money from this job? What person, business, or agency pays this person? This job pays: every week every 2 weeks every month
Does this job pay hourly? Yes No How many hours each week? How much gross income will this job If yes, how much each hour? $ pay this month? $
Job 4 Who earns money from this job? What person, business, or agency pays this person? This job pays: every week every 2 weeks every month
Does this job pay hourly? Yes No How many hours each week? How much gross income will this job If yes, how much each hour? $ pay this month? $ Use the space on page 15 if you need to tell us about more money from work.
If any income has recently changed or will be changing in the next month or two, please let us know why (for example, “I just lost my job,” or “My hours at work have been cut.”). If your income is going to be less, please let us know what you expect your gross income (before taxes and deductions) to be next month.
Need help? Please call 1-800-699-9075 (TTY 711). Monday to Friday 7 a.m. to 6 p.m. page ? 5 OHA 7210W (Rev 6/12) 8 Does anyone in your home get money from places other than work? Yes No If yes, tell us about this month’s income for anyone in your home who is related to you or your children (including expected children). You must send proof (see the checklist on page 16). Tell us about money, including: • rent paid to you • worker’s compensation • dividends or interest on investments • loans repaid to you • disability benefits • tribal payments • TANF (Temporary Assistance for • child or spousal support • unemployment compensation Needy Families) • guardian or foster care payments • educational income (such as financial aid) • retirement pension • Social Security benefits • other: • veterans benefits • Supplemental Security Income (SSI)
1st kind of income Write the kind of income here. How much this month? Who gets this income? from list above $
What person, business, or agency pays this person? How often? every week every 2 weeks every month
2nd kind of income Write the kind of income here. How much this month? Who gets this income? from list above $
What person, business, or agency pays this person? How often? every week every 2 weeks every month
3rd kind of income Write the kind of income here. How much this month? Who gets this income? from list above $
What person, business, or agency pays this person? How often? every week every 2 weeks every month Use the space on page 15 if you need to tell us about more money from other places.
9 Resources. Tell us about resources that belong to anyone in your home who is related to you or your children (including expected children), including: • checking accounts • cash • stocks and bonds • savings accounts • certificates of deposit • IRAs and 401(k)s
Resource 1 Kind of resource Value This resource belongs to: $
Resource 2 Kind of resource Value This resource belongs to: $
Resource 3 Kind of resource Value This resource belongs to: $ Use the space on page 15 if you need to tell us about more resources.
10 Vehicles and other property. Tell us about all vehicles, such as cars, trucks, or motorcycles, and other property, such as land or buildings, that belong to anyone in your home who is related to you or your children (including expected children).
Vehicle 1 Model year Model make How much is it worth? How much is still owed? Who owns this vehicle? $ $
Vehicle 2 Model year Model make How much is it worth? How much is still owed? Who owns this vehicle? $ $
Other property 1 Kind of property How much is it worth? How much is still owed? Who owns this property? Do not include the home you live in. $ $
Other property 2 Kind of property How much is it worth? How much is still owed? Who owns this property? Do not include the home you live in. $ $ Use the space on page 15 if you need to tel us about more vehicles or other property.
Need help? Please call 1-800-699-9075 (TTY 711). Monday to Friday 7 a.m. to 6 p.m. page ? 6 OHA 7210W (Rev 6/12) 11 Does anyone 18 years or younger who you want medical coverage for have a disability, a kidney disorder, or a condition that, without treatment, would be life-threatening or cause permanent loss of function or disability? Yes No If yes, who? If anyone 19 years or older who you want medical coverage for has a kidney disorder or a serious disability that prevents them from working, please fill out Extra Form D on page 12.
12 Does anyone in your home (related to you or your children) who is 19 years or older have health insurance now, or did they in the last 6 months? Yes No Does anyone in your home (related to you or your children) who is 18 years or younger have health insurance now, or did they in the last 2 months? Yes No If yes to one or both of these questions, please fill out Extra Form E on pages 13 and 14.
Coverage within the last Coverage was lost because Coverage within the last 2 Coverage within the last 2 months 2 months was through a parent lost a job, had their months was through OMIP, was through Kaiser Permanente COBRA hours reduced, or it was no FMIP, or Family Health Child Health Insurance or Kaiser Yes No longer offered through work Insurance Assistance Program Transition Program If yes, who? Yes No If yes, who? Yes No If yes, who? Yes No If yes, who?
Is anyone in your home who is applying for benefits able to get insurance through an employer? Yes No If yes, who?
13 You can name a person to whom we can release information. This person can give or get information about your case, but cannot sign your application. You do not need to list people already listed on this form. See page 19 of the Green Booklet for more information.
Name (first, middle initial, last) Phone number
14 You can name an authorized representative. This person can give or get information about your case, and can sign your application. You do not need to list people already listed on this form. See page 19 of the Green Booklet for more information.
Name of authorized representative (first, middle initial, last) Phone number
15 Is someone helping you fill out this application? Yes No If yes, please tell us about the person helping you.
Name (first, middle initial, last) Phone number
This person is my: authorized representative legal guardian attorney in fact Healthy Kids grantee or assister OHP outreach and enrollment worker other:
16 If you speak a primary language other than English, please list it here: Do you want future information in this other language or in another format? Yes No See page 1 of this application or the cover of the Green Booklet for formats. Please tell us which format you would prefer:
Need help? Please call 1-800-699-9075 (TTY 711). Monday to Friday 7 a.m. to 6 p.m. page ? 7 OHA 7210W (Rev 6/12) 17 Choosing a plan. There may be a Coordinated Care Organization, or CCO, available in your community. CCOs are local networks of doctors, mental health providers, hospitals and other providers. They work together for patient-centered care for people on the Oregon Health Plan and Healthy Kids. See pages 20– 23 of the Green Booklet for more information.
• Read more about CCOs at www.health.oregon.gov.
We encourage you to choose a CCO and dental plan or a medical and dental plan. If you don’t make a choice, we may choose for you. Before you pick, you might want to ask your doctor and dentist which plans they accept. Read the list of plans at www.oregon.gov/dhs/healthplan.
Write your first and second choices for CCOs and dental or medical and dental plans below. Sometimes the first choice is full. Depending on which program your children qualify for, we may send you a letter asking you to choose another medical plan.
CCO - 1st choice CCO - 2nd choice
Dental plan - 1st choice Dental plan - 2nd choice OR Medical plan - 1st choice Medical - 2nd choice
Dental plan - 1st choice Dental plan - 2nd choice
American Indians and Alaska Natives who want to be enrolled in plans. American Indians, Alaska Natives and people who have access to care through Indian Health Services may choose to enroll into a Coordinated Care Organization (CCO) or a managed care plan where available. You may also choose to be enrolled in a dental and/or mental health plan only. If you are enrolled in a CCO or a managed care plan, you can still access services at Indian Health Services, the Urban Indian Program or through the Tribal Health Clinic.
• If American Indian or Alaska Native and you choose to enroll in plans, use the boxes above to write your plan choices.
• If American Indian or Alaska Native and you choose not to enroll in a plan, use the lines below. List who does not want to be enrolled in a medical plan, dental plan, mental health plan or Coordinated Care Organization:
These people do not want to be enrolled in a Medical Plan: Name(s) ______
These people do not want to be enrolled in a Dental Plan: Name(s) ______
These people do not want to be enrolled in a Mental Health Plan: Name(s) ______
These people do not want to be enrolled in a Coordinated Care Organization: Name(s) ______
If you don’t enroll in a plan, you will be covered by an open card that allows you to get care through Indian Health Services, Tribal Health Clinics and other providers based on your area. You can let your worker know at anytime if you decide you would like to be enrolled into a plan.
Need help? Please call 1-800-699-9075 (TTY 711). Monday to Friday 7 a.m. to 6 p.m. page ? 8 OHA 7210W (Rev 6/12) Extra Forms A, B, C, D, and E are on the next 6 pages. Please read through each form and complete the ones that you need to fill out. Sign and submit this application on page 18.
Extra Form A: People in Your Home A People. If you have filled out Part 2 of the application and need more space to tell us about everyone in your home, use this form.
Person 7 Name (first, middle initial, last) Are you applying for health coverage for Sex female this person? Yes No male
City of birth State of birth Date of birth (month, day, year) Maiden or birth name
This is my husband or wife child Your answers to these questions help us, but you can choose stepchild other: not to answer. If you are applying for this person, you must tell us about Ethnicity Hispanic/Latino Not Hispanic/Latino citizenship and Social Security: Race (choose one or more) American Indian or Alaska Native Asian Black or African American Is this person a U.S. citizen? Yes No Native Hawaiian or other Pacific Islander White If no, and this person has an Alien Resident number, write it here: Is this person an Alaska Native or a member of a federally Social Security number: If this person does not have recognized American Indian tribe? Yes No a Social Security number, Does this person receive services through Indian Health Services check this box: now or could this person receive services? Yes No
Person 8 Name (first, middle initial, last) Are you applying for health coverage for Sex female this person? Yes No male
City of birth State of birth Date of birth (month, day, year) Maiden or birth name
This is my husband or wife child Your answers to these questions help us, but you can choose stepchild other: not to answer. If you are applying for this person, you must tell us about Ethnicity Hispanic/Latino Not Hispanic/Latino citizenship and Social Security: Race (choose one or more) American Indian or Alaska Native Asian Black or African American Is this person a U.S. citizen? Yes No Native Hawaiian or other Pacific Islander White If no, and this person has an Alien Resident number, write it here: Is this person an Alaska Native or a member of a federally Social Security number: If this person does not have recognized American Indian tribe? Yes No a Social Security number, Does this person receive services through Indian Health Services check this box: now or could this person receive services? Yes No
Person 9 Name (first, middle initial, last) Are you applying for health coverage for Sex female this person? Yes No male
City of birth State of birth Date of birth (month, day, year) Maiden or birth name
This is my husband or wife child Your answers to these questions help us, but you can choose stepchild other: not to answer. If you are applying for this person, you must tell us about Ethnicity Hispanic/Latino Not Hispanic/Latino citizenship and Social Security: Race (choose one or more) American Indian or Alaska Native Asian Black or African American Is this person a U.S. citizen? Yes No Native Hawaiian or other Pacific Islander White If no, and this person has an Alien Resident number, write it here: Is this person an Alaska Native or a member of a federally Social Security number: If this person does not have recognized American Indian tribe? Yes No a Social Security number, Does this person receive services through Indian Health Services check this box: now or could this person receive services? Yes No Use the space on page 15 if you need to tell us about more people in your home.
Need help? Please call 1-800-699-9075 (TTY 711). Monday to Friday 7 a.m. to 6 p.m. page ? 9 OHA 7210W (Rev 6/12) Extra Form B: Absent Parents B Absent parents. If you have filled out Part 6 of the application and need space to tell us about other absent parents, use this form.
Absent parent 3 Name (first, middle initial, last) This is my spouse or ex-spouse partner or ex-partner child stepchild other: Sex female Address City State ZIP code male
Date of birth (month, day, year) Social Security number (if you know it) Date this parent stopped living with the child (month, day, year)
List this parent’s children if you have Hours each week this parent spends If this is an absent father, has paternity been legally included those children on this application. with the child: established? Yes No I don’t know Can the child or children get health Do you think this parent might hurt you or the insurance through this parent? child if we try to find out about paternity or Yes No I don’t know health insurance? Yes No
Absent parent 4 Name (first, middle initial, last) This is my spouse or ex-spouse partner or ex-partner child stepchild other: Sex female Address City State ZIP code male
Date of birth (month, day, year) Social Security number (if you know it) Date this parent stopped living with the child (month, day, year)
List this parent’s children if you have Hours each week this parent spends If this is an absent father, has paternity been legally included those children on this application. with the child: established? Yes No I don’t know Can the child or children get health Do you think this parent might hurt you or the insurance through this parent? child if we try to find out about paternity or Yes No I don’t know health insurance? Yes No
Absent parent 5 Name (first, middle initial, last) This is my spouse or ex-spouse partner or ex-partner child stepchild other: Sex female Address City State ZIP code male
Date of birth (month, day, year) Social Security number (if you know it) Date this parent stopped living with the child (month, day, year)
List this parent’s children if you have Hours each week this parent spends If this is an absent father, has paternity been legally included those children on this application. with the child: established? Yes No I don’t know Can the child or children get health Do you think this parent might hurt you or the insurance through this parent? child if we try to find out about paternity or Yes No I don’t know health insurance? Yes No Use the space on page 15 if you need to tell us about more absent parents.
Need help? Please call 1-800-699-9075 (TTY 711). Monday to Friday 7 a.m. to 6 p.m. page ? 10 OHA 7210W (Rev 6/12) Extra Form C: Self-Employment C Is anyone in your home self-employed? Yes No If yes, fill out this form. Send all available proof of income and expenses for the most recent month available (see the checklist on page 16). 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.
Tell us about this business and income from self-employment. Business name (if there is one) Is your office located within your home? Yes No
What does this business do? Is this business incorporated? Gross income this month (before expenses) Yes No $ Business address City State Business phone number
Tell us about your business expenses. Here is a list of many kinds of expenses. Please tell us about your business expenses, whether or not they are on the list. • business property (rent, taxes and assessments, utilities, interest • advertising (such as newspaper ads, business cards, signs, flyers) on mortgage, insurance premiums) • interest paid on business loans • equipment (services, repair and rental of business equipment, • telephone for business taxes and assessments) • travel (20 cents per mile. Do not count commuting costs.) • professional fees, legal fees, licenses and permits (such as book- • cost of materials purchased for resale (such as cosmetic products. keeper, attorney) For newspaper carriers, include the cost of newspapers, bags, and • operating supplies (such as stationery, postage, cleaning supplies) rubber bands.) • repairs to business equipment or motor vehicles • cost of materials used to make a product
1st business expense Kind of expense How much this month? $
2nd business expense Kind of expense How much this month? $
3rd business expense Kind of expense How much this month? $
4th business expense Kind of expense How much this month? $
5th business expense Kind of expense How much this month? $
6th business expense Kind of expense How much this month? $
7th business expense Kind of expense How much this month? $
8th business expense Kind of expense How much this month? $
9th business expense Kind of expense How much this month? $
10th business expense Kind of expense How much this month? $ Use the space on page 15 if you have more expenses.
Need help? Please call 1-800-699-9075 (TTY 711). Monday to Friday 7 a.m. to 6 p.m. page ? 11 OHA 7210W (Rev 6/12) Extra Form D: Disability or Kidney Disorder
D Do any adults (19 or older) for whom you are applying have a mental or physical disability or kidney disorder? Yes No If yes, fill out this form.
Person 1 Name Tell us about this person’s disability or medical condition.
Has this disability lasted more than 1 year? Yes No Will this disability last more than 1 year? Yes No
Have you applied for disability benefits through the Social Security Administration (SSA) for this disability? Yes No If yes, and you got a decision letter, tell us: Date of your application (month, year) When did you get a decision letter? (month, year) Your application was approved denied If your application was denied Did you appeal? Yes No If yes, what was the appeal date? (month, year)
Has the disability gotten worse since you If yes, when did the disability get worse? (month, year) were denied benefits? Yes No Tell us how it got worse: Is there a new medical condition since you If yes, when did it start? (month, year) were denied benefits? Yes No Tell us about the new condition:
Person 2 Name Tell us about this person’s disability or medical condition.
Has this disability lasted more than 1 year? Yes No Will this disability last more than 1 year? Yes No
Have you applied for disability benefits through the Social Security Administration (SSA) for this disability? Yes No If yes, and you got a decision letter, tell us: Date of your application (month, year) When did you get a decision letter? (month, year) Your application was approved denied If your application was denied Did you appeal? Yes No If yes, what was the appeal date? (month, year)
Has the disability gotten worse since you If yes, when did the disability get worse? (month, year) were denied benefits? Yes No Tell us how it got worse: Is there a new medical condition since you If yes, when did it start? (month, year) were denied benefits? Yes No Tell us about the new condition:
Tell us about any adult (19 or older) in your home who has end-stage renal disease, has regular dialysis, or who has had a kidney transplant in the past 3 years.
Person 1 Name
Person 2 Name
Need help? Please call 1-800-699-9075 (TTY 711). Monday to Friday 7 a.m. to 6 p.m. page ? 12 OHA 7210W (Rev 6/12) Extra Form E: Other Insurance Office Use Only Program Branch Worker ID Case Number E Please note: Many medical programs allow you to have other insurance and still Case Name qualify for medical benefits from the state. Rush Processing | Reason: TPL / Good cause coding 0 1 2 3 4 5 6 7
Section 1
Does anyone in your home (related to you or your children) have employer-sponsored or privately paid health insurance or have they had it recently? This would include medical, dental, vision, pharmacy, long-term care, accident, student, or other types of health insurance policies. Yes No If yes, fill out this form. Send copies of the front and back of insurance cards. If you are applying for adults (age 19 or older), we need this information for the past 6 months. If you are applying for children (age 18 or younger), we need this information for the past 2 months.
Section 2: Status of insurance – check all that apply
Have active insurance Insurance is paid for privately Insurance is through COBRA Insurance has changed Insurance is from an employer Date insurance is or was no longer available ___/___/____ If you pay for all or part of your insurance, we may be able to reimburse you. For more information, see Section 5 on the next page.
Section 3: Policy 1 information
Insurance company Policy ID Number
Policy holder’s* name (first, middle initial, last) Social Security number Date of birth (month, day, year)
Type of policy (check all that apply): Medical Dental Pharmacy Vision Other:
* The policy holder is the owner of the insurance policy.
List all people covered by Policy 1 who are applying for or receiving medical benefits.
Person 1 Applicant or client name Date of birth (month, day, year) Prime number (Office use only)
Person 2 Applicant or client name Date of birth (month, day, year) Prime number (Office use only)
Person 3 Applicant or client name Date of birth (month, day, year) Prime number (Office use only)
Person 4 Applicant or client name Date of birth (month, day, year) Prime number (Office use only)
Person 5 Applicant or client name Date of birth (month, day, year) Prime number (Office use only)
more on the next page
Need help? Please call 1-800-699-9075 (TTY 711). Monday to Friday 7 a.m. to 6 p.m. page ? 13 OHA 7210W (Rev 6/12) Section 4: Policy 2 information
Insurance company Policy ID Number
Policy holder’s* name (first, middle initial, last) Social Security number Date of birth (month, day, year)
Type of policy (check all that apply): Medical Dental Pharmacy Vision Other:
* The policy holder is the owner of the insurance policy.
List all people covered by Policy 2 who are applying for or receiving medical benefits.
Person 1 Applicant or client name Date of birth (month, day, year) Prime number (Office use only)
Person 2 Applicant or client name Date of birth (month, day, year) Prime number (Office use only)
Person 3 Applicant or client name Date of birth (month, day, year) Prime number (Office use only)
Person 4 Applicant or client name Date of birth (month, day, year) Prime number (Office use only)
Person 5 Applicant or client name Date of birth (month, day, year) Prime number (Office use only)
Section 5: Possible premium reimbursement
In some cases, the state’s Health Insurance Premium Payment (HIPP) program may reimburse people who pay for employer-sponsored or private major medical health insurance if it is cost-effective for the state. Do you pay for all or part of your private or employer-sponsored health insurance premium? Yes No If you answered yes, we will contact you and ask for more information to see if you qualify for this type of premium reimbursement.
Section 6: Use this section for any additional information you want to provide about your current or recent insurance coverage.
Please return this completed form and copies of your insurance cards (front and back) with your application. Let us know in the space above if you do not have your insurance cards.
Need help? Please call 1-800-699-9075 (TTY 711). Monday to Friday 7 a.m. to 6 p.m. page ? 14 OHA 7210W (Rev 6/12) 18 Room for more information. If you ran out of room on any of the questions, please use this area to give us that information. Be sure to tell us what question you are answering and answer all parts of the original question.
Need help? Please call 1-800-699-9075 (TTY 711). Monday to Friday 7 a.m. to 6 p.m. page ? 15 OHA 7210W (Rev 6/12) 19 Your checklist.
I looked at Extra Forms (A, B, C, D, and E) and completed the ones that I needed to fill out.
I have copies of documents that I need for each person who is applying.
Immigration status. If you are not a U.S. citizen and are applying for benefits you should: • Include your Alien Resident number and Social • You do not need to be a U.S. citizen to apply Security number on the application (if you have for medical benefits for yourself or your children. one or both). AND • Send a copy of your immigration card/green card or copies of immigration legal papers.
For Alaska Natives or American Indians. Please include a copy of one of these: • American Indian Tribal Enrollment card • letter showing Indian Health Services • certification of Indian blood program eligibility
Money from work. Please include a copy of one of these for each person who has money from work: • Send in something that shows the person’s gross • If you fill out the self-employment form, you must income (before taxes and deductions) for this also send proof of any income and expenses you write month, such as a pay stub or a letter from the about on that form. Proof could be bookkeeping employer. Be sure to send proof for every job listed records, contracts, work agreements, payroll records for each working person. or sales receipts. Tax returns may also be accepted if If no pay has been received for this month, please no other proof is available. give us a pay stub from within the last 30 days. For example, if you are applying in September and haven’t yet received pay for September, give us the last pay stub for August (even though this income is not listed on your application).
Money from other places. Please include a copy of one of these for each kind of money you listed in part 7: • check stubs • award letters • written proof You do not need to submit proof of income from TANF, Social Security benefits including disability (SSDI) and Supplemental Security Income (SSI), or unemployment benefits received from Oregon. Medical coverage. Please include a copy of this for each person with medical coverage listed on Extra Form E: • copies of the front and back of any health insurance cards, including private insurance, Medicaid from other states, or insurance through an employer
Pregnancy. Please include a copy of this for each pregnant person: • copy of a letter from a doctor or clinic saying this person is pregnant
I printed a copy of the application and all proof needed for my records. (Print this form before hitting the ‘submit’ button on page 18.)
Need help? Please call 1-800-699-9075 (TTY 711). Monday to Friday 7 a.m. to 6 p.m. page ? 16 OHA 7210W (Rev 6/12) 20 Important notes and your responsibilities. When you sign your name on this application it means that:
• You read this application, or someone has read it to you, and you • If the person receiving benefits dies, be it you or your child, understand the questions. the state may recover the amount of medical benefits received −−State, federal, and local officials may check the information that after the age of 55 from the estate of the person who received you gave about yourself and anyone who is applying. They do benefits. This includes monthly payments made by DHS or OHA to this because it may help decide if you should get benefits. managed care plans. −−We will check Department of Human Services and/or the • In cases where the person receiving benefits is in an institution Oregon Health Authority (DHS or OHA) computer systems and (such as a nursing home) for 6 months prior to death, the state other agency offices, including child support, for information will recover money for all medical benefits provided regardless of about you and the people applying. age when received. −−We may check your U.S. citizen or non-citizen status. • The state will not claim this money if the person receiving benefits • The information you put on this application is true, complete, and has children who are under age 21, blind, or permanently and correct as far as you know. totally disabled. −−It is against the law to provide false information. If you do not • If the person receiving benefits has a spouse, the state will wait tell the truth on this application or give information that is not until the spouse dies before claiming the money. complete, you may be breaking the law and could be fined and face jail time. You may have to pay for any benefits that you Social Security number (SSN) – These federal laws say that received by mistake. anyone applying for medical benefits must provide an SSN: • You have read the Green Booklet and agree to all sections. Federal laws – 42 USC 1320b-7(a), 7 USC 2011-2036, • Representatives from DHS or OHA can look at the health records 42 CFR 435.910, 42 CFR 435.920, and 42 CFR 457.340(b). of anyone who is applying. The reason they look is for the When you write your SSN on the application it means that you purpose of providing health benefits. give permission for DHS or OHA to use it and tell others about it • Starting today, you will turn over rights to any health insurance for these reasons: payments to DHS or OHA. For example, if you have an accident or • To help us decide if you qualify for benefits. We will use the injury, DHS or OHA will have the right to any financial support or SSNs to make sure the income and assets you gave on the payments for medical care from the person who is responsible. application are correct. We will match that information with −−You must cooperate with DHS or OHA to identify and provide other state and federal records, such as Internal Revenue information about anyone who may be responsible for paying Service, Department of Revenue, Medicaid, child support, for your care. Social Security, and unemployment benefits. • To write reports about the Oregon Health Plan or Healthy Kids. • You will try to find out about any other benefits for which you (or • If the SSN is needed in order to administer the program you anyone for whom you are applying) might qualify. This includes apply for or receive benefits from. cash medical support and health care coverage from absent • To help us improve the programs by doing quality reviews and parents, unless (1) you think the absent parent would cause harm other activities. to you or your child, or (2) your child is receiving state Children’s • To make sure that we have given you the correct amount of Health Insurance Program benefits. benefits and to recover money if we have overpaid benefits.
See pages 23–25 of the Green Booklet for the full list of your rights and responsibilities.
Please be sure to sign this form on the next page.
Need help? Please call 1-800-699-9075 (TTY 711). Monday to Friday 7 a.m. to 6 p.m. page ? 17 OHA 7210W (Rev 6/12) 21 Sign this online application by typing in your name (first name, middle initial, last name). Be sure to include your phone number.
Your signature: Phone number:
print Click here to print a copy for your records before you submit.
After you have printed your copy, read the checklist, and filled out any Extra Forms, submit click here to submit this application.
22 Next steps. • Mail your copies of documents listed on page 16 to: OHP Processing Center PO Box 14520 Salem, OR 97309-5044 • Or, you can fax these copies to 503-373-7493 • A caseworker will call or send you a letter if you need to send any other information. • We will decide what benefits you are eligible for within 45 days. If you do not get a letter within 45 days after you submit your application, call 1-800-699-9075 (TTY 711).
Need help? Please call 1-800-699-9075 (TTY 711). Monday to Friday 7 a.m. to 6 p.m. page ? 18 OHA 7210W (Rev 6/12)