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_______________ REGIONAL OFFICE Appendix A-16-1-RB283 DIVISION OF MEDICAID (DATE) (ADDRESS) (CITY,STATE,ZIP)

ID#: 00000000000000 (NAME) SSN#: 000-00-0000 (ADDRESS) SSI APPLICATION DATE: 00/00/0000 (CITY,STATE,ZIP)

DIVISION OF MEDICAID

NOTICE OF APPROVAL AND RETROACTIVE MEDICAID

The Division of Medicaid has been informed by the Social Security Administration that you are eligible for Supplemental Security Income (SSI). Individuals who are eligible for SSI are also eligible for Medicaid. Your eligibility for Medicaid begins (DATE). You will receive a plastic Medicaid card soon. This card is good for each month you are eligible.

If you have medical bills in the three months prior to your application for SSI, or for the month(s) between your application for SSI and the month your SSI payment began, notify the regional office shown below and show them this letter to verify receipt of SSI/Medicaid. If you are found eligible for Medicaid during any of these months, some or all of your medical bills may be paid.

ADDRESS: REGIONAL OFFICE DIVISION OF MEDICAID (ADDRESS) (CITY,STATE,ZIP)

TELEPHONE: _______________

Your eligibility for Medicaid will continue as long as you remain eligible for SSI. It is important that you notify your local Social Security Office in (LOCATION OF SSA OFFICE) of any change in address or circumstances as soon as possible.

Enclosure: Medicaid Notice of Non-Discrimination