Page 25

COMAR 10.09.24.15

1524

State of Maryland Medical Assistance Manual Revised July 2012 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 personal information, the Medicaid Program may deny your application for benefits. You have a 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 federal and state law. DHMH 4245 Revised 7/02