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.