Page 20

COMAR 10.09.24.05

519

State of Maryland Medical Assistance Manual Revised July 2012

Attachment A- Proof of Citizenship and Identity Proof of Citizenship Proof of Identity U.S. Birth Certificate

Data match of Vital Statistics records by DHMH to document birth record Systematic Alien Verification for Entitlements (SAVE)-for naturalized citizens only

For child under 16: a record created near the date of birth, or 5 years before initial MA/MCHP application, and showing U.S. place of birth on hospital letterhead or other medical record.

Record showing U.S. place of birth, if created at least 5 years before initial MA/MCHP application: record on hospital letterhead or other medical record created near the date of birth, institutional admission papers, signed statement by physician or midwife who attended the birth, Vital Statistics notice of birth registration, insurance record

Final adoption decree for child born in U.S.

Certificate of citizen born abroad (DS-1350, FS-240,FS-545)

Early school record that shows a U.S. place of birth, the date of admission to the school, date of birth (or age at the time the record was made), and the name(s) and place(s) of birth of the applicant’s parent(s)

Religious record - recorded in the U.S. within three months of birth showing US birth, and either the date of the birth or the individual’s age at the time the record was made. The record must be an official record recorded with the religious organization, not the family bible

U.S. military service record showing U.S. place of birth

Evidence of U.S. civil service employment before 6/1/76

Federal or state census record for 1900-1950 showing U.S. citizenship or U.S. place of birth

ID card for naturalized citizen (I-179 or I-197)

Affidavits (can also be used for naturalized citizens) Three written and signed affidavits. Two completed by citizens who have personal knowledge of the person's citizenship, one of whom is not a relative. Both signers must be US citizens. Another affidavit completed by the person, representative, or someone else knowledgeable to explain why the proof isn't available

Photo driver's license or Motor Vehicle Administration (MVA) ID card

Data match with other benefit programs(current or past TCA, Food Stamps, DAP, SSI eligibility) to document identity

Photo school ID card

Photo ID issued by a federal, state, or local government

U.S. military ID card, discharge document, or draft record

Native American Tribal Document

US Coast Guard Merchant Mariner card

For children under 16: Clinic, doctor, hospital, or school record (e.g., DHR/FIA604 or 604-A form), nursery or day care record including pre-school health forms and Form 1131. School records may include report cards but these records must be verified with the issuing school.

Three or more corroborating documents to prove identity such as marriage licenses, divorce decrees, high school and college diplomas, property deeds/titles, and employer ID cards. This process can be used if they are unable to produce a single, more reliable document such as a driver’s license. (These may only be used if the individual did not use affidavits to verify citizenship.)

Note: Recently expired identity documents are usable as long as there is no reason to believe the document does not match the individual.

Affidavits can be used for the following:

For Children under 16 written affidavit signed by parent or guardian- but only if an affidavit was not used as proof of citizenship.

Disabled individuals (Adult/Child) in long term care or rehabilitative residential care facilities; signed by Facility Director or Administrator.