Fourth Level Documents (also requires verification of identity)

This level of documents should only be used in extremely rare of circumstances when either Primary, Secondary, or Third Level documents are unavailable; document the situation in Gateway.

Federal or State census record showing U.S citizenship or U.S. place of birth (generally for persons born 1900 through 1950). The census record must also show the applicant’s age. To secure this information the applicant, member or worker should complete a Form BC-600, Application for Search of Census Records for Proof of Age. Add in the remarks portion “U.S. citizenship data requested”. Also add that the purpose is for Medicaid eligibility. This form requires a fee. The BC-600 is also available online at: www.census.gov/history/pdf/bc-600-2013.pdf

Institutional admission papers from a nursing home, skilled nursing care facility or other institution indicating a U.S. place of birth and was created at least 5 years before the initial application date

Medical (clinic, doctor, or hospital) record indicating a U.S. place of birth and was created at least 5 years before the initial application date The Form 3231 immunization from the Department of Public Health (DPH) is acceptable if an immunization date on the form was documented before the individual’s 16 th birthday.

Other document that shows a U.S. place of birth and that was created at least five years before the application for Medical Assistance (or for children under 16 near the time of birth). These documents are a Seneca Indian tribal census record, Bureau of Indian Affairs tribal census records of the Navajo Indians, a U.S. State Vital Statistics official notification of birth registration, a delayed U.S. public birth record that was recorded more than 5 years after the person’s birth, a statement signed by the physician or midwife who was in attendance at the time of birth, and the Bureau of Indian Affairs Roll of Alaska Natives.

Form 219 Citizenship or Identity Affidavit (only used in rare circumstances as a last resort) by two individuals of whom one is not related to the applicant/recipient and who have personal knowledge of the event(s) establishing the applicants or recipient’s claim of citizenship. The person(s) making the affidavit must be able to provide verification of his/her own citizenship and identity for the affidavit to be accepted. (A copy of the verification should be maintained in the case record.) A third affidavit from the applicant/recipient or other knowledgeable individual must also be obtained explaining why documentary evidence does not exist or cannot be obtained. An affidavit may be used to verify citizenship of anyone or identity of a child, but not both.