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State of Maryland Medical Assistance Manual Revised April 2014
Maryland Medical Assistance Program Request for Life Insurance Information
SECTION I (To Be Completed By Case Manager)
Date: ____________________________
Case Manager_______________________________________ CID# ____________________________ Telephone Number___________________________________ District Office (D.O.) _______________
D.O Address________________________________________
________________________________________ Name of Insurance Company _________________________________ Address ___________________________________________________
Re: Customer Name ____________________________________________
SSN ______________________________________________________
D.O.B._______________
SECTION II (To Be Completed By Applicant)
I AUTHORIZE THE RELEASE OF INFORMATION TO THE DEPARTMENT OF SOCIAL SERVICES
___________________________
____________________ Signature
Date
NOTICE TO MEDICAID APPLICANT You are providing personal information (Name, Address, Date of Birth, Income History, Employment History, etc.) in this application for Medicaid benefits. The purpose of requesting this personal information is to determine your eligibility for Medicaid.
If you do not provide this information, the Medicaid Program may deny your application for benefits. You have the right to inspect, amend or correct this personal information. The Medicaid Program will not permit inspection of your personal information, or make it available to others, except as permitted by law.
DES 2001 (LTC) Revised 12/08
(1)