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COMMONWEALTH OF VIRGINIA DEPARTMENT OF SOCIAL SERVICES
Breast and Cervical Cancer Prevention and Treatment Act (BCCPTA) Medicaid Application
AGENCY USE ONLY DATE RECEIVED:
CASE NAME/NUMBER:
LOCALITY:
WORKER
Please complete all sections. If you need assistance, please contact an eligibility worker at your local Department of Social Services. 1. IDENTIFYING INFORMATION LAST NAME:
FIRST NAME:
MI:
SOCIAL SECURITY NUMBER:
ADDRESS:
CITY: STATE:
ZIP: STATE OF RESIDENCE:
MAILING ADDRESS (If different): CITY: STATE:
ZIP: HOME PHONE #: DAYTIME PHONE #:
2. ADDITIONAL INFORMATION RACE:
WHITE AMERICAN INDIAN/ALASKA NATIVE
MARITAL STATUS: NEVER MARRIED
DIVORCED
BLACK ASIAN/PACIFIC ISLANDER
MARRIED
WIDOWED
HISPANIC OTHER
SEPARATED
DATE OF BIRTH:
PLACE OF BIRTH: ________________________________________________________________________ U. S. CITIZEN? YES NO
IF NO, ALIEN NUMBER: DO YOU RECEIVE SSI? YES NO
ARE YOU PREGNANT? YES NO
DO YOU HAVE A CHILD(REN) UNDER AGE 19 LIVING WITH YOU? YES NO
DO YOU HAVE HEALTH INSURANCE? YES NO
IF YES, COMPANY NAME: __________________________________________________________________ POLICY #: EFFECTIVE DATE: TYPE OF COVERAGE: _____________________________________________
DID YOU RECEIVE MEDICAL CARE IN ANY OF THE THREE MONTHS BEFORE THIS APPLICATION? YES NO
IF YES, LIST MONTHS: ___________________________
3. BCCPTA CERTIFICATION
I CERTIFY THAT THE ABOVE NAMED INDIVIDUAL IS A VIRGINIA BREAST AND CERVICAL CANCER EARLY DETECTION PROGRAM (BCCEDP) PARTICIPANT (TITLE XV) AND IS ELIGIBLE FOR MEDICAID UNDER THE BREAST AND CERVICAL CANCER PREVENTION AND TREATMENT ACT OF 2000.
SCREENING DATE: _______________ DIAGNOSIS DATE: _______________ FACILITY/SERVICE SITE: ______________________________ PHONE #: ___________________
SIGNATURE OF BCCEDP CASE MANAGER : ____________ DATE: ______________________________________
032-03-384/1 Manual Title Chapter Page Revision Date Virginia Medical Assistance Eligibility M01 January 2003 Subchapter Subject
Page M0120 MEDICAL ASSISTANCE APPLICATION Appendix 1 1