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MISSISSIPPI DIVISION OF MEDICAID Eligibility Policy and Procedures Manual CHAPTER 102 – Non-Financial Requirements Page |31 Effective Date: January 2019 or cannot be obtained, and the applicant/beneficiary alleges being born in the U.S. In addition, a second document establishing identity must be obtained. Third Level Documents Explanation Medical records, including but not limited to, hospital, clinic, or doctor records or admission papers from a nursing facility, skilled care facility or other institution that indicates a U.S. place of birth. Do not accept a souvenir “birth certificate” issued by the hospital. Life or health or other insurance record which shows a U.S. place of birth. Life or health insurance records may show biographical information for the person including place of birth; the record can be used to establish U.S. citizenship when it shows a U.S. place of birth. Official religious record recorded in the U. S. showing that the birth occurred in the U.S. The record must be an official record with a religious organization. In questionable cases, i.e., religious document recorded near an international border, the religious record must be verified and/or verify that the mother was in the U. S. at time of birth. NOTE: Entries in a family Bible are not considered religious records. School records, including pre- school, Head Start and daycare, showing the child’s name and U.S. place of birth. The record must show the name of the child, the date of admission to the school, the date of birth (or age at the time record was created), and a U. S. place of birth. Fourth level evidence of citizenship is of the lowest reliability. It should only be used in the rarest of circumstances. It is used when primary evidence is not available and both secondary and third level evidence do not exist or cannot be obtained within the reasonable opportunity period and the applicant alleges a U. S. place of birth. In addition, a second document establishing identity must be obtained. Accept any of the following documents as fourth level evidence of U. S. citizenship if the document meets the listed criteria, the applicant/beneficiary alleges U. S. citizenship and there is nothing indicating the person is not a U. S. citizen or lost U. S citizenship. Fourth level evidence consists of documents established for a reason other