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MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |30 Secondary Documents Explanation Certificate of birth in the U.S. This is a form created by the birthing hospital that is sent to Vital Records and used to create an official birth certificate. U. S Citizen ID Card (I-197) or prior version I-179 The former Immigration and Naturalization Service (INS) issued the I-179 from 1960 until 1973. It revised the form and renumbered it as form I-197. INS issued the I-197 from 1973 until April 7, 1983. INS issued Form I-179 and I-197 to naturalized U.S. citizens living near the Canadian or Mexican border who needed it for frequent border crossings. Although neither form is currently issued, either form that was previously issued is still valid. Northern Mariana Card (I-873) INS issued the I-873 to a collectively naturalized citizen of the U.S. who was born in the NMI before November 4, 1986. The card is no longer issued, but those previously issued are still valid. Final adoption decree The adoption decree must show the child’s name and U.S. place of birth. In situations where an adoption is not finalized and the State in which the child was born will not release a birth certificate prior to final adoption, a statement from a State-approved adoption agency that shows the child’s name and U.S. place of birth is acceptable. The adoption agency must state in the certification that the source of the place of birth information is an original birth certificate. Evidence of civil service employment by the U.S. government The document must show employment by the U.S. government before June 1, 1976. Official military record of service The document must show a U.S, place of birth (for example a DD-214 or similar official document showing a U.S. place of birth). Third level evidence of citizenship is documentary evidence of satisfactory reliability that is used when primary or secondary evidence of citizenship is not available. Third level evidence may only be used when primary and secondary evidence does not exist Effective Date: July 2025