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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 Refugee • USDHS Form I-94, Arrival/Departure Record, showing entry under section 207 of the INA. • USDHS Form I-766, Employment Authorization Document, annotated “A3.” • USDHS Form I-571, Refugee Travel Document. NOTE: Refugees who have adjusted to lawful permanent resident status are still considered refugees for Medicaid eligibility. If a refugee has a Form I-551, Permanent Resident Card*, it will be annotated RE-6, RE-7, RE-8, RE-9 or R8-6. Eligible regardless of U.S. entry date Veteran or active duty military personnel lawfully admitted for permanent residence (and families) To verify alien status: • 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-55I” stamp. To verify military status: • Honorably discharged veteran: Original or notarized copy of form DD214 (discharge papers). NOTE: This verification is sufficient when the veteran is a U.S. citizen, and the spouse or unmarried dependent children (or surviving spouse and unmarried dependent children of a deceased veteran) are aliens. • Active duty: Original or notarized copy of the current orders showing the person is on full-time duty in the U.S. Army, Navy, Air Force, Marine Corps, or Coast Guard, or a DD form 2 military ID card (active duty papers). Eligible regardless of U.S. entry date Other (legal or illegal) Documents that indicate the person’s alien status is one other than those specifically listed under Aliens Subject to Five-Year Bar (MS D-223) or under Aliens Exempt from Five-Year Bar (MS D-224). Ineligible regardless of U.S. entry date The below chart lists the immigration status for lawfully present alien children under age 19 and pregnant women who are exempted from the five year bar waiting period: Alien Status Acceptable Documentation of Alien Status Children under 19 and Pregnant Women Qualified alien • USDHS Form I-551, Permanent Resident Card. • Any verification from the immigration authorities or other authoritative documents indicating Qualified Alien. Eligible and exempted from the 5 year bar. Valid Non- immigrant Status • USDHS Form I-94, Arrival/Departure record. • Any verification from the immigration authorities or other authoritative documents indicating nonimmigrant status. Eligible and exempted from the 5 year bar. (This status includes non- immigrants from Micronesia, Marshall Islands, and Palau.)