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State of Maryland Medical Assistance Manual Revised July 2012

American Indian Card (I-872): issued by the U.S. Department of Homeland

Security to identify a U.S. citizen member of the Texas Ban of Kickapoo’s living near

the U.S./ Mexican border. A classification code of “KIC” and a statement on the

back denote U.S. citizenship. Northern Mariana Card (1-873) o Issued by the INS to a collectively naturalized citizen of the U.S. who was born in the Northern Mariana Islands before November 4, 1986. Although no longer issued, a form that was previously issued is still valid.

One the following 3rd level documents may be used to document citizenship if none of the 1st or 2nd level documents are available within the time limit for determining eligibility: Extract of a hospital records on hospital letterhead that shows a U.S. place of birth: o The hospital record must have been established at the time of the person’s birth and created at least 5 years before the initial application date for MA.

Example: A redetermination is being conducted for October 2006 for an individual who initially applied for MA in October 2003. The hospital record must have been created before October 1998 and must have been established at the time of the individual’s birth (in order to verify the individual’s birth in the U.S.). For a child younger than 16 years old, the document must have been created either

near the time of birth or at least 5 years before the initial application date for MA or

MCHP. Do not accept a souvenir “birth certificate” issued by the hospital. Life, health, or other insurance record showing a U.S. place of birth: The record must have been created at least 5 years before the initial application date for MA or MCHP.

One of the following 4th level documents may be used to document citizenship if none of the 1st, 2nd, or 3rd level documents are available within the time limit for determining eligibility. Documentation with this low level of reliability should only be used in the rarest of circumstances. Federal or state census record for 1900-1950 showing U.S. citizenship or a U.S. place of

birth; the census record must also show the individual’s age. To secure this information,

the individual or state must 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 Medical Assistance eligibility. A fee is charged for this

form. Medical record (clinic, doctor, or hospital) that shows a U.S. place of birth: 1. The record must have been established at the time of the person’s birth and created at least 5 years before the initial application date for MA or MCHP.