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Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M01 January 2019 Subchapter Subject

Page M0120 MEDICAL ASSISTANCE APPLICATION TOC i

TABLE OF CONTENTS

M01 APPLICATION FOR MEDICAL ASSISTANCE

M0120.000 MEDICAL ASSISTANCE APPLICATION

Section Page

Applying for Medical Assistance ............................................. M0120.100.............................. 1

When an Application Is Required .............................................. M0120.150 .............................. 1

Who Can Sign the Application ................................................. M0120.200.............................. 2

Application Forms ..................................................................... M0120.300.............................. 9

Place of Application .................................................................. M0120.400............................ 12

Receipt of Application ............................................................... M0120.500............................ 16

Appendices

Sample Letter Requesting Signature……………………………Appendix 1……………….1

The Breast and Cervical Cancer Prevention and Treatment Act (BCCPTA) Medicaid Application, form #032-03-384………………………….…Appendix 2.…………….…1

Interstate Compact on Adoption and Medical Assistance (ICAMA) Member States and Reciprocity………………..Appendix 3…….………….1