Page 12

Medical Services – Appendix C, Verification of Citizenship, Alien Status and SSN Enumeration Revised (05/18) Alien Status Acceptable Documentation of Alien Status Medicaid Status Conditional Entrant Proof of admission or entry date and one of the following documents: • USDHS Form I-94, Arrival/Departure Record, with stamp showing admission under section 203(a)(7) of the INA. • USDHS Form I-766, Employment Authorization Document, annotated “A3.” Barred for five years if entered U.S. on or after 8/22/96. Eligible if entered U.S. before 8/22/96 Cuban or Haitian Entrant • USDHS Form I-551, Permanent Resident Card, annotated CU6, CU7 or CH6. • Unexpired temporary I-551 stamp in a foreign passport annotated AM1, AM2 or AM3. • USDHS Form I-94, Arrival/Departure Record, annotated CU6 or CU7, or with a stamp showing parole as “Cuban/Haitian Entrant” under section 212(d)(5) of the INA. Eligible regardless of U.S. entry date Cuban or Haitian Entrants in the Haitian Family Reunification Program • USDHS Form I-130, Petition for Alien Relative. • USDHS Form I-131, Application for Travel Document. • USDHS Form I-134, Affidavit of Support. • USDHS Form I-765, Application for Employment Authorization. Once paroled into the United States, HFRP Program beneficiaries will meet the definition of Cuban/Haitian entrants under section 501(e)(1) of the Refugee Education and Assistance Act of 1980, as amended, and will be qualified aliens Eligible regardless of U.S. entry date. Deportation or removal withheld • USDHS Form I-766, Employment Authorization Document, annotated “A10.” • Order of an immigration judge showing deportation withheld under section 243(h) or removal withheld under section 241(b)(3) of the INA and date of grant. Eligible Regardless of U.S. entry date Lawfully admitted for permanent residence • USDHS Form I-551, Permanent Resident Card. • Unexpired “Temporary I-551” stamp in a foreign passport. • USDHS Form I-94, Arrival/Departure Record, with a temporary I-551 stamp. Barred for five years if entered U.S. on or after 8/22/96 Eligible if entered U.S. before 8/22/96 Paroled into U.S. for at least one year Proof of admission or entry date and USDHS Form I-94, Arrival/Departure Record, showing admission for at least one year under section 212(d)(5) of the INA. NOTE: The applicant cannot use admission periods for less than one year to meet the one-year requirement. Barred for five years if entered U.S. on or after 8/22/96 Eligible if entered U.S. before 8/22/96