Declaration of Citizenship/Immigrant Status

A separate declaration is not required if the application/renewal form was completed and signed under penalty of perjury by an adult assistance unit (AU) member or Authorized Representative (AREP). Applications cannot be denied, and renewals cannot be terminated for failure to provide the Declaration of Citizenship form 216 when these conditions have been met. The Declaration of Citizenship form 216 can be used, when necessary, as a standalone form if citizenship of an applicant/recipient cannot be verified by electronic data sources and was not declared previously by an adult AU member or AREP who can attest to the individual’s citizenship.

A parent or guardian applying for Medical Assistance may declare citizenship or immigration status on behalf of a child or ward 18 years of age or younger.

Effective November 30, 2016, any other individual 18 years of age or older included in the application for Medical Assistance does not have to sign the application or a separate declaration of citizenship (Form 216) unless the applicant does not have knowledge of the person’s citizenship or immigration status.

Examples of individuals who might have knowledge of another person’s citizenship or immigration status and can make declaration on another person’s behalf include:

Parent

Spouse

Friend

An Adult Family Member

Acquaintance who can attest to knowing the person’s status. This list is not inclusive.

Declaration of Citizenship/Immigration status/Identity Form 216 is not required if the A/R has declared their citizenship or immigrations status on the eligibility application (94, 94A, 297, 508, 700, or via Gateway Customer Portal application) and signed application under penalty of perjury. Also, declaration of citizenship/immigration status/identity is not required if the A/R is determined under EMA procedures.

EXCEPTIONS:

Children who meet “deemed newborn” status do not have to have a written declaration of citizenship until the next redetermination of eligibility or change in Class of Assistance (COA).

Do not require a written declaration of citizenship/immigrant status for a foster care or adoption assistance child.

Do not require a written declaration of citizenship/immigrant status for any applicant who indicates inability or unwillingness to do so. Failure to complete a declaration of citizenship will result in a citizen being ineligible for Medical Assistance. Classify a qualified immigrant as a non-qualified immigrant and consider eligibility only for EMA. Refer to 2054 Emergency Medical Assistance .

EMA applicants/recipients are not required to declare citizenship/immigration status.