101.03.02 DOM APPLICATION FORM(S)

DOM uses three types of application forms to determine eligibility: • For MAGI-related purposes, the Mississippi Application for Health Benefits is the single streamlined application form used to apply for Medicaid and CHIP. Information from this form is also used to refer individuals to the FFM for health coverage if ineligible for health coverage through DOM.For Family Planning purposes, the Application for Family Planning is the streamlined application form used to apply specifically for the Family Planning waiver program coverage. • For ABD purposes, the Application for Mississippi Medicaid Aged, Blind and Disabled Medicaid Programs is used. • The MAGI-related, Family Planning, and ABD applications forms may be a paper version, an electronic version, or an exact facsimile of the appropriate form. • Applications filed for Medicaid coverage through other agencies or entities have their own Medicaid applications, such as CPS, SSI,HPE or PEP. • The application form is a legal document, completed by the applicant or representative that signifies intent to apply and: o Is the official agency document used to collect information necessary to determine eligibility; o Is the applicant’s formal declaration of financial and other circumstances at the time of application; o Is the applicant’s certification that all information provided is true and correct; o Provides notice to the applicant of his rights and responsibilities; and o May be introduced as evidence in a court of law.