Mandatory Forms

Complete the mandatory forms below when processing a Family Medical Assistance application:

Application for Assistance (Obsolete as of 09/2017)

Form 297A - Rights & Responsibilities ( only if Form 297 is used to apply).

Form 216 - Declaration of Citizenship/Immigration Status (conditionally mandatory, please see Note below) This form is not required if Form 94 (Rev. 5/10 or later), Form 94A - Medicaid Streamlined Application , 297 - Application for TANF, Food Stamps, or Medical Assistance , 508 - Food Stamp TANF Medicaid Renewal Form (Rev. 5/12 or later), 700 - Application for Medicaid & Medicare Savings for Qualified Beneficiaries (Rev. 11/09 or later), Gateway Medical Assistance Online application, or GA Access application are used as they contain the required language to meet the needs of the declaration.

Form 5460 - Notice of Privacy Practices (HIPAA) Form 5460 - Notice of Privacy Practices (HIPAA) 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 the forms were sent.

Form DMA 285 - Third Party Liability Questionnaire, when the person has other health insurance coverage. See Section 2230 - Third Party Liability for when a Form DMA 285 - Third Party Liability Questionnaire can be waived, and for other TPL requirements. A Form DMA 285 - Third Party Liability Questionnaire is not required for children in placement. For MAGI COAs a separate Form DMA 285 - Third Party Liability Questionnaire is not required if the Form 94A - Medicaid Streamlined Application or pre-populated renewal form 508M has the TPL information included, and the form is signed.

Form 138 - Notice of Requirement to Cooperate and Right to Claim Good Cause for Refusal to Cooperate in Child Support Services (if a DCSS referral is required) Form 138 - Notice of Requirement to Cooperate and Right to Claim Good Cause for Refusal to Cooperate in Child Support Service may be mailed to the applicant. The applicant is NOT required to sign and return the form provided the case record is documented that the form was sent. If the application or renewal is completed using Gateway Medical Assistance Application, Gateway Medical Assistance Renewal, or Form 94A - Medical Assistance Streamlined Application , then Form 138 – Notice of Requirement to Cooperate and Right to Claim Good Cause for Refusal to Cooperate in Child Support Services is not required as the 138’s language is included.

When the Form 94A - Medicaid Streamlined Application is used it also incorporates the Declaration of Citizenship/Immigration status and TPL; separate forms are not required.

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