Appendix K - Renewal Form HUSKY Health (Medicaid and CHIP) <BARCODE> Renewal Form Do not use this form if you are not <FNLNS of the Head of Household> <FNLNS of the Head of Household> <mail date> <Street Address> Respond by: <45 day deadline date> <City, State Zip> Person ID: <MPI ID> Client ID: <EMS ID> It is time to renew your HUSKY Health (HUSKY A, B or D) coverage. You can renew your HUSKY Renewing online is faster! Go to www.accesshealthct.com, sign-in and then click Health (Medicaid & CHIP) in on the Report a Change/Renew Coverage link. By phone: Just call 1-855-805-4325 (TTY: 1-855-789-2428). The call is free. any one of these ways By mail: Complete this form and mail it to: Access Health CT / DSS PO Box #670 Manchester, CT 06045-0670 In person: Visit www.ct.gov/dss for a listing of all DSS Regional Office locations and directions. Or call 1-866-6 CONNECT (1-866-626-6632) for the m 4:30 pm, Monday through Friday. How to complete this 1. Review all of the questions on the form. renewal form 2. Read the information about you and each member of your household. Add any missing information. If any information has changed, write in the correct information. 3. Sign the form in Section 9. 4. Return this form by <45 day deadline date>. If you do not return the form by this deadline, you will lose your HUSKY Health coverage. What we need We need information about each person living in your household or listed on your tax return, including: those who get HUSKY Health now, those who do not get HUSKY Health now but would like to apply, and others who live in the household and do not get HUSKY Health but do not want to apply. We will check your answers using information from computer data sources, including the Internal Revenue Service (IRS), the Social Security Administration, the Department of Homeland Security and others. If the information does not match, we may ask you to send more information. If you do not qualify for If you do not qualify for HUSKY Health, Access Health CT will check to see if you HUSKY Health (Medicaid & qualify for other kinds of health coverage. CHIP) If you have questions about Call Access Health CT at 1-855-805-4325. The call is free. TTY: 1-855-789-2428. your renewal Or visit www.accesshealthct.com. AH3-R Page 3 of 18 Form AH3-R revised 07/14/2014 Appendix K - Renewal Form Person ID: <MPI ID> <BARCODE> Client ID: <EMS ID> 1 Your contact information Review your contact information here Correct any wrong or missing information here Fred Flintstone Name (first middle last suffix) Check here if you are homeless. Home address: Home address Apartment # 12 Boulder Street Bedrock, CT 12345-1234 City (home) State ZIP Code Mailing address: Mailing address Apartment # 12 Boulder Street Bedrock, CT 12345-1234 City (mailing) State ZIP Code Phone: Best phone to reach you: Home: 555-222-3333 Number: Home Work Cell Other: 555-122-1234 Email: Preferred email address: [email protected] Communication preference: Preferred communication: Paper/US Mail Paper/US Mail Email AH3-R Call Access Health CT at 1-855-805-4325. The call is free. TTY: 1-855-789-2428. Or visit www.accesshealthct.com. Page 4 of 18 Appendix K - Renewal Form Person ID: <MPI ID> <BARCODE> Client ID: <EMS ID> 2 We need information about who files tax returns You can still renew if you do not file tax returns. Review your tax information below and correct any wrong or missing information for everyone in your household who plans to file a federal tax return for the year <year of first day of coverage> Tax Filer 1 Name (first middle last suffix): Fred Flintstone Is this person planning to file taxes? Yes No If yes, Is this person married? Yes No If yes, are they filing jointly? Yes No Name of spouse: Wilma Flintstone Names of dependents: (a) Pebbles Flintstone (c)_____________________________ (b) Grandma Flintstone (d)_____________________________ Will this Tax Filer be claimed as a Yes No If yes, name of the tax filer: __________________________ return? Tax Filer 2 Name (first middle last suffix): _____________________________ Is this person married? Yes No If yes, are they filing jointly? Yes No Name of spouse: __________________________ Names of dependents: (a) ___________________________ (c)___________________________ (b) ___________________________ (d)___________________________ Will this Tax Filer be claimed as a Yes No If yes, name of the tax filer: __________________________ return? , write the name of the tax filer and the dependents below. Review any existing information that we have and correct as needed. Answer only if different than what you reported above or if you did not fill in any information above. Tax Dependent 1 Name of dependent (first middle last suffix): Bam Bam Rubble Name of tax filer (first middle last suffix): Barney Rubble Does the dependent reside at a different address Yes No than the tax filer? If yes, provide the address: Tax Dependent 2 Name of dependent (first middle last suffix): Name of tax filer (first middle last suffix): Does the dependent reside at a different address Yes No than the tax filer? If yes, provide the address: Tax Dependent 3 Name of dependent (first middle last suffix): Name of tax filer (first middle last suffix): Does the dependent reside at a different address Yes No than the tax filer? If yes, provide the address: AH3-R Call Access Health CT at 1-855-805-4325. The call is free. TTY: 1-855-789-2428. Or visit www.accesshealthct.com. Page 5 of 18 Appendix K - Renewal Form Person ID: <MPI ID> <BARCODE> Client ID: <EMS ID> These are the people in your household who get HUSKY Health and who 3 now need to renew Person 1: Fred Flintstone HUSKY A Check here if this Has this person had their current immigration status for 5 or more years? person is no longer Yes No living in the household. Check here if this person no longer wants HUSKY Health. Person 2: Wilma Flintstone HUSKY A Check here if this Access Health CT does not Write it in the person is no longer space below living in the household. __ __ __ - __ __ - __ __ __ __ If this person does not have an SSN please check any of the following that are applicable: Check here if this Not eligible to receive an SSN person no longer Has non-work type visa and so an SSN is not required wants HUSKY Health. Has this person had their current immigration status for 5 or more years? Yes No Is this person Pregnant? Yes No If yes, with how many babies? _____ Due date: ___________ Person 3: Pebbles Flintstone HUSKY B Check here if this Is this person Pregnant? person is no longer Yes No If yes, with how many babies? _____ Due date: ___________ living in the household. Is this person a full-time high school or technical/vocational student who will graduate before Check here if this turning 19 years old? person no longer Yes No wants HUSKY Health. AH3-R Call Access Health CT at 1-855-805-4325. The call is free. TTY: 1-855-789-2428. Or visit www.accesshealthct.com. Page 6 of 18 Appendix K - Renewal Form Person ID: <MPI ID> <BARCODE> Client ID: <EMS ID> 4 We need more information about people NOT listed in Section 3 Tell us about anybody else in your household or on your tax return. Review the details below and correct any wrong or missing information. Other person 1: Grandma Flintstone HUSKY A Check here if this person is no longer in the household. Date of birth (mm/dd/yyyy): 9/15/1923 This person is a: Male Female How is this person related to you? Grandmother Other person 2: Grandpa Flintstone Check here if this person is no longer in the household. Access Health CT does not Date of birth (mm/dd/yyyy): Security number. Write it in the space below: 4/5/1933 __ __ __ - __ __ - __ __ __ __ This person may choose not to give the Social Security Number if This person is a: Male Female he or she is not applying but it helps us to have it. How is this person related to you? Grandfather If this person does not have an SSN please check any of the following that are applicable: Not eligible to receive an SSN Has non-work type visa and so an SSN is not required identification numbers Check here if the person wants health care coverage and fill out Attachment A. Other person 3: Name (first middle last suffix): Access Health CT does not Date of birth (mm/dd/yyyy): Security number. Write it in the space below: __ __ __ - __ __ - __ __ __ __ This person may choose not to give the Social Security Number if This person is a: Male Female he or she is not applying but it helps us to have it. How is this person related to you? If this person does not have an SSN please check any of the following that are applicable: Has applied for an SSN Not eligible to receive an SSN Has non-work type visa and so an SSN is not required identification numbers Is this person a full-time high school or technical/vocational student who will graduate before turning 19 years old? Yes No Check here if the person wants health care coverage and fill out Attachment A.