Mandatory Forms

Complete the mandatory forms below when processing an ABD Medicaid application.

Application for Assistance (AFA) (Obsolete as of 09/2017)

Form 297A, Rights and Responsibilities ( only if Form 297 is used to apply)

Form 5460 - Notice of Privacy Practices (HIPAA) Form 5460 - Notice of Privacy Practices and Form 297A - Rights and Responsibilities may be mailed to the applicant. The applicant is NOT required to sign and return either form, provided the case record is documented that these forms were sent.

Form 216 - Declaration of Citizenship (conditionally mandatory, see Note below) This form is not required if 94 (rev. 5/10 or later), Form 94A, 297, 508 (Rev. 5/12 or later), 700 (Rev.11/09 or later), Gateway Medical Assistance application, or FFM application are used as they contain the required language to meet the needs of the declaration.

Form DMA 285 - Third Party Liability Health Insurance Questionnaire, when the person has other health insurance coverage. See Section 2230 - Third Party Liability for requirements. A Form DMA 285 - Third Party Liability Questionnaire is not required when application is made for QMB, SLMB, or QI-1 via Form 700. Send a copy of Form 700 to DCH/TPL in lieu of Form DMA 285 if the client has medical insurance. Attach a copy of the insurance card, front and back, if available.

Complete any other forms as necessary depending on the COA and the A/R’s circumstances.