Appendix V, Levels of Evidence of Citizenship and Acceptable Evidence of Identity Reference Guide

Revision 07-4; Effective October 1, 2007

Important: Current SSI recipients and individuals entitled to or enrolled in Medicare are exempt from the citizenship documentation requirement for Medicaid. This includes individuals determined disabled for Social Security benefits and in the 24-month period before receiving Medicare.

Primary Evidence of Citizenship and Identity U.S. passport Certificate of naturalization Certificate of U.S. citizenship SDX for denied SSI recipients when the denial is for any reason other than citizenship (N13) SOLQ/WTPY and documentation of reason for Medicare denial

If primary evidence of citizenship is not available, the individual must provide two documents – one to establish U.S. citizenship and one to establish identity. Acceptable evidence of identity documents is outlined last at the end of this reference guide.

When primary evidence of citizenship is not available, begin with the second level of evidence of citizenship and continue through the levels to locate the best available documentation.

Second Level of Evidence of Citizenship (Use only when primary evidence is not available.) A U.S. public birth certificate showing birth in one of the 50 states, the District of Columbia, Puerto Rico (if born on or after Jan. 13, 1941), Guam (on or after April 10, 1899), the Virgin Islands of the U.S. (on or after Jan. 17, 1917), American Samoa, Swain’s Island or the Northern Mariana Islands (after Nov. 4, 1986). Conduct Bureau of Vital Statistics (BVS) inquiry for an individual born in Texas. If an individual’s date of birth is earlier than 1903 or if the birth was out of state, accept a legible/non-questionable copy. For a birth out of state, individuals may obtain a birth certificate through the following: BirthCertificate.com; vitalchek.com; or usbirthcertificate.net. Individuals may also contact usbirthcertificate.net toll-free at:1-888-736-2692. Report of Birth Abroad of a U.S. Citizen (FS-240) Certification of Birth Abroad (FS 545 or DS-1350) U.S. Citizen Identification card (Form I-179 or I-197) Northern Mariana Identification card (I-873) American Indian card (I-872) issued by Department of Homeland Security with classification code “KIC” Final adoption decree showing the child’s name and U.S. place of birth Evidence of U.S. Civil Service employment before June 1, 1976 U.S. Military record showing a U.S. place of birth ( Example: DD-214)

Third Level of Evidence of Citizenship (Use only when primary and second level evidence is not available.) Hospital record of birth showing a U.S. place of birth Life, health or other insurance record showing a U.S. place of birth Religious record of birth recorded in the U.S. or its territories within three months of birth that indicates a U.S. place of birth showing either the date of birth or the individual’s age at the time the record was made Early school record showing a U.S. place of birth, name of the child, date of admission to the school, date of birth, and name(s) and place(s) of birth of the applicant’s/recipient’s parents

Fourth Level of Evidence of Citizenship (Use only when primary, second level and third level evidence is not available.) Any listed documents used must include biographical information, including U.S. place of birth. Federal or state census record showing U.S. citizenship or a U.S. place of birth and the individual’s age (generally for individuals born 1900-1950) Seneca Indian Tribal census record showing a U.S. place of birth Bureau of Indian Affairs Tribal census records of the Navajo Indians showing a U.S. place of birth Bureau of Indian Affairs Roll of Alaska Natives U.S. State Vital Statistics official notification of birth registration showing a U.S. place of birth Statement showing a U.S. place of birth signed by the physician or midwife who was in attendance at the time of birth Institutional admission papers from a nursing facility, skilled care facility or other institution showing a U.S. place of birth Medical (clinic, doctor or hospital) record, excluding an immunization record, showing a U.S. place of birth Affidavits from two adults regardless of blood relationship to the individual; use only as a last resort when no other evidence is available

Evidence of Identity Driver's license issued by a state either with a photograph or other identifying information such as name, age, sex, race, height, weight or eye color School identification card with a photograph U.S. Military card or draft record Identification card issued by the federal, state or local government with the same information included on driver’s license Department of Public Safety identification card with a photograph or other identifying information such as name, age, sex, race, height, weight or eye color Birth certificate Hospital record of birth Military dependent’s identification card Native American Tribal document U.S. Coast Guard Merchant Mariner card Certificate of Degree of Indian Blood or other U.S. American Indian/Alaskan Native and Tribal document with a photograph or other personal identifying information Data matches with other state or federal government agencies ( Example: Employee Retirement System and Teacher Retirement System) Three or more corroborating documents, such as marriage license, divorce decrees, high school diplomas and employer ID cards. Use only with second and third levels of evidence of citizenship. Adoption papers or records Work identification card with photograph Signed application for Medicaid (accept signature of an authorized representative or a responsible person acting on the individual’s behalf) Health care admission statement For children under 16, school records may include nursery or day care records For children under 16, clinic, doctor or hospital records For children under 16, an affidavit signed by a parent or guardian stating the date and place of birth of the child; use as a last resort when no other evidence is available and if an affidavit is not used to establish citizenship For disabled individuals in residential care facilities, an affidavit signed by the facility director or administrator attesting the identity of the individual when the individual does not have or cannot get any document on this list. Use as a last resort when no other evidence is available and if an affidavit is not used to establish citizenship.