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Chapter: 1400 Technical Requirements Program: MFAM 3

The following can be used to document U.S. citizenship and identity:

1. A U.S. passport (can be expired), 2. A Certificate of Naturalization (DHS form N-550 or N-570), 3. A Certificate of Citizenship (DHS form N-560 or N-561) or, 4. Data from the Driver’s And Vehicle Express (DAVE) system, 5. Data from the Federal Data Services Hub.

The following can only be used to verify citizenship (must show a U.S. place of birth):

1. BVS record (MNOV or DEBP) if born in Florida, 2. VIS-CPS (SAVE) for naturalized citizens (must have their A#), 3. Verification of eligibility under the Child Citizenship Act of 2000, including the U.S. citizenship of the parent, 4. A U.S. birth certificate (originally issued prior to age five) (except for voided Puerto Rican birth certificates after September 30, 2010), 5. A final adoption decree, or if the adoption is pending and no birth certificate can be issued, a statement from the state adoption agency (U.S. born children), 6. A Report of Birth Abroad of a U.S. citizen (forms FS-240, FS-545 or DS1350), 7. A U.S. Citizen I.D. card (DHS form I-197 or I-179), 8. A Northern Mariana ID card (I-873), 9. An American Indian card (I-872, with “KIC” code), 10. Proof of civil service employment before 6/1/76, or 11. Official military record of service (ex.DD-214).

If none of the above documents exist or can be located, the following documents can be used to verify U.S. citizenship if they show a U.S. place of birth and are dated five years prior to the Medicaid application (unless for a child under age five):

1. Extract of hospital birth record on hospital letterhead (not a souvenir birth certificate), 2. Life or health insurance record with a U.S. place of birth, 3. Early school record, or 4. Religious record (ex baptism) within three months of birth.

If none of the above documents exist or can be located, the following documents can be used to verify U.S. citizenship if they show a U.S. place of birth and are dated five years prior to the Medicaid application (unless for a child under age five):

1. Federal census records from 1900-1950 showing the age and place of birth (the five year rule does not apply), 2. Tribal census records, 3. An amended birth certificate, after age five, 4. A signed statement from the doctor or midwife who was present at the birth, 5. Nursing home institution records that contain biographical information, 6. Medical records with biographical information, 7. Listed on the roll of Alaskan natives, or 8. A written statement signed under penalty of perjury by at least two people who have personal knowledge of the event(s) – (One cannot be related.). They must also prove their own citizenship and identity. A separate statement by the applicant/recipient/representative, signed under penalty of perjury, must also be completed stating why the documentation could not be obtained.