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Medical Services – Appendix C, Verification of Citizenship, Alien Status and SSN Enumeration Revised (05/18) Alien Status Acceptable Documentation of Alien Status Medicaid Status Asylee • USDHS Form I-94, Arrival/Departure Record, noting admittance under section 208 of the INA. • USDHS Form I-94, Arrival/Departure Record, annotated AS-1, AS-2 or AS-3. • USDHS Form I-94, Arrival/Departure Record, with Visa 92 or V-92. • Order of an immigration judge granting asylum. • Written decision letter from the Board of Immigration Appeals. • USDHS Form I-730, Approval Letter. • USDHS Form I-766, Employment Authorization Document, annotated “A5.” Eligible as of date asylum is granted Battered Alien Proof of admission of entry date and one of the following documents: • I-360 or I-130 petition with proof of filing (a file-stamped copy of the petition or another document demonstrating filing, such as a signed certified return receipt or cash register or computer-generated receipt). • Order or document from the Immigration Court or Board of Immigration Appeals granting suspension of deportation under INA section 244(a)(3), or cancellation or removal under INA section 204A(b)(2). • Application for cancellation of removal (Form EOIR 42B) or suspension of deportation (Form EOIR 40) with proof of filing (a file-stamped copy of the application or another document demonstrating filing, such as a signed certified return receipt or cash register or computer-generated receipt). • A document from the Immigration Court or Board of Immigration Appeals indicating that the applicant has established a prima facie case for suspension of deportation under INA section 244(a)(3), or cancellation of removal under INA section 204A(b)(2). Barred for five (5) years if entered U.S. on or after 8/22/96 Eligible if entered U.S. before 8/22/96 Canadian-born American Indian • USDHS Form I-551, Alien Registration Receipt Card, coded S13. • I-551 stamp in a Canadian passport coded S13. • USDHS Form I-94, Arrival/Departure Record, coded S13. • Proof of tribal membership or a tribal document showing the individual has at least 50% American Indian blood. Proof of membership can be a tribal membership card, other tribal documents showing membership, or collateral contact with the tribe’s government. Eligible Regardless of U.S. entry date