Page 170

child was born will not release a birth certificate prior to final adoption, a statement from a State approved adoption agency that shows the child’s name and US place of birth is acceptable. The adoption agency must state in the certification that the source of the place of birth information is an original birth certificate. Evidence of civil service employment by the US government The document must show employment by the US government before June 1, 1976. Official Military record of service The document must show a US place of birth (for example a DD-214 or similar official document showing a US place of birth). Third Level Documents to Establish US Citizenship (Chart 3) Third level evidence of US citizenship is documentary evidence of satisfactory reliability that is used when neither primary nor secondary evidence of citizenship is available. Third level evidence may be used ONLY when primary evidence cannot be obtained within 45 days for AR/AX or 90 days for SR/QM, secondary evidence does not exist or cannot be obtained, and the applicant or recipient alleges being born in the US In addition, a second document establishing identity MUST be presented as described in Chart 5, Evidence of Identity. Accept any of the documents listed in Chart 3 as third level evidence of US citizenship if the document meets the criteria listed under “Explanations and Notes”, the applicant alleges birth in the US, and there is nothing indicating the person is not a US citizen (e.g., lost US citizenship). Third level evidence is generally a non-government document established for a reason other than to establish US citizenship and to show a US place of birth. The place of birth on the non-government document and the Medicaid application must agree. Chart 3 – Third Level Evidence of Citizenship Third Level Documents Explanations and Notes on Documentation Extract of hospital record on hospital letterhead established at the time of the person’s birth and was created at least 5 years before the initial application date and indicates a US place of birth Do not accept a souvenir “birth certificate” issued by the hospital. Note: For children under 16 the document must have been created near the time of birth or 5 years before the date of application Life or health or other insurance record showing a US place of birth and was created at least 5 years before the initial application date Life or health insurance may show biographical information for the person including place of birth; the record can be used to establish US citizenship when it shows a US place of birth. Fourth Level Documents to Establish US Citizenship (Chart 4) Fourth level evidence of US citizenship is documentary evidence of the lowest reliability. Fourth level evidence should ONLY be used in the rarest of circumstances. This level of evidence is used ONLY when primary evidence is not available, both secondary and third level evidence do not exist or cannot be obtained within 45 days for AR/AX or 90 days for SR/QM, and the applicant or recipient alleges being born in the US In addition, a second document establishing identity MUST be presented as described in Chart 5, Evidence of Identity. Available evidence is evidence that can be obtained within 45 days.