Printable PEAK Application

Transcription

1 Printable PEAK Application **Keep in mind that you do not need to mail this print-out to your local application site.** Log in to your PEAK Account today to begin managing your benefits., your application has been submitted to El Paso on 11/10/2015 7:39. In your application, you have asked for these benefits: Medical Assistance (including Health First Colorado (Colorado Medicaid), CHP+, Tax Credits, and Cost Sharing Reductions) Basic Information Your Name Date of Birth Gender County 02/06/1946 Female El Paso I have no home address/i am homeless right now. Preferred Spoken Language Tagalog Preferred Written Language English Where You Live 6835 CEDAR EDGE DR COLORADO SPRINGS, Colorado Home Phone Cell Phone Message/Work Phone Message/Work Type Mailing Address 6835 CEDAR EDGE DR COLORADO SPRINGS, Colorado Address mildredmanulat@yahoo.com Secondary Phone Secondary Phone Type Address tification Method mildredmanulat@yahoo.com US Mail People In Your Home 1 of 14

2 Person: Date of Birth Gender Marital Status 02/06/1946 Female Widowed Language Has this person ever used another name (such as maiden name, alias, etc)? If yes, please list: First Name, Middle Name and Last Name Received benefits in another state? English Programs received out of state Received from which state Last date person received benefits Programs Requested Medical Assistance (including Health First Colorado (Colorado Medicaid), CHP+, Tax Credits, and Cost Sharing Reductions) Backdate Month for Medical Assistance Has this person applied for a Social Security Number? SSN Reason for not applying? TIN US Citizen? Citizenship Status n-citizenship status n-citizen Document? Legal Permanent Resident Yes n-citizen/document Number n-citizen/document Expiration n-citizen/document Country of Issuance Alternate Name on n-citizen/document Date Asylum Granted Document Number: Card Number Class Code Spouse or parent a veteran or active-duty member U.S. military? Document Type Was Lilia a U.S citizen in June,May or April? Was Lilia's non-citizenship status different in May,April or March? Month the change occurred Temp Resident Card 2 of 14

3 n-citizenship status n-citizen Document? n-citizen/document Number n-citizen/document Expiration Yes n-citizen/document Country of Issuance Alternate Name on n-citizen/document Document Type Date Asylum Granted Document Number: Card Number Class Code Resident of Colorado? Plan to stay as a resident of Colorado? Lived in the US since 1996? Migrant Worker? Yes Yes Where does this person live? Is this person living outside of Colorado temporarily? Living in Colorado when he or she returns Has this household member passed away in the coverage year? Living with one other person Date of Death Did this person move in to the household in May,April or March? When did this person move in? Has this person moved out of the household in May,April or March? When did this person move out? Funeral Preference Ethnicity Race Filipino Does this person plan to file a Federal Income Tax Return? Does this person expect to be claimed as tax dependent on someone else's tax return? What is this person's tax filing status? Exceptional circumstances apply to this persons case. Is this person living with both parents, but the parents do not expect to file a joint return? Does this person expect to be claimed by a non-custodial parent? Did this person file a Federal Income Tax Return in 2014? Was this person claimed as a tax dependent on someone else's tax return in 2014? Did this person live with both parents, but the parents did not file a joint return in 2014? Was this person claimed by a non-custodial parent in 2014? Secondary Account Holder Does this person have an individual shared responsibility exemption? 3 of 14

4 Exemption Certificate Number Has health insurance coverage? Person: Date of Birth Gender Marital Status 03/31/1981 Female Single-Never Married Language Has this person ever used another name (such as maiden name, alias, etc)? If yes, please list: First Name, Middle Name and Last Name Received benefits in another state? English Programs received out of state Received from which state Last date person received benefits Programs Requested Backdate Month for Medical Assistance SSN TIN Has this person applied for a Social Security Number? Reason for not applying? US Citizen? Citizenship Status n-citizenship status n-citizen Document? n-citizen/document Number n-citizen/document Expiration n-citizen/document Country of Issuance Alternate Name on n-citizen/document Date Asylum Granted Document Number: Card Number Class Code Spouse or parent a veteran or active-duty member U.S. military? Document Type Was Mildred a U.S citizen in June,May or April? Was Mildred's non-citizenship status different in May,April or March? Month the change occurred 4 of 14

5 n-citizenship status n-citizen Document? n-citizen/document Number n-citizen/document Expiration n-citizen/document Country of Issuance Alternate Name on n-citizen/document Document Type Date Asylum Granted Document Number: Card Number Class Code Resident of Colorado? Plan to stay as a resident of Colorado? Lived in the US since 1996? Migrant Worker? Where does this person live? Is this person living outside of Colorado temporarily? Living in Colorado when he or she returns Has this household member passed away in the coverage year? Date of Death Did this person move in to the household in May,April or March? When did this person move in? Has this person moved out of the household in May,April or March? When did this person move out? Funeral Preference Ethnicity Race Does this person plan to file a Federal Income Tax Return? Does this person expect to be claimed as tax dependent on someone else's tax return? What is this person's tax filing status? Exceptional circumstances apply to this persons case. Yes Single Is this person living with both parents, but the parents do not expect to file a joint return? Does this person expect to be claimed by a non-custodial parent? Did this person file a Federal Income Tax Return in 2014? Was this person claimed as a tax dependent on someone else's tax return in 2014? Did this person live with both parents, but the parents did not file a joint return in 2014? Was this person claimed by a non-custodial parent in 2014? Secondary Account Holder Does this person have an individual shared responsibility exemption? Exemption Certificate Number Has health insurance coverage? Relationship Information 5 of 14

6 Person Relationships Do they buy food and eat meals together? Tax Dependents is the Mother of Responsible Relative American Indian / Alaska Native You've told us that no one in your home is a member of a tribe, or receiving or eligible for Indian or Tribal health services. Legal Information Lilia's Legal Information Prosecution, Custody, Jail, Parole Probation Food Assistance or Cash Assistance Disqualification Avoiding Prosecution Probation / Parole Drug Felony Conviction Released from Incarceration Current Incarceration Convicted of felony on or after 02/07/2014 In compliance with felony conviction? Mildred's Legal Information Prosecution, Custody, Jail, Parole Probation Food Assistance or Cash Assistance Disqualification Avoiding Prosecution Probation / Parole Drug Felony Conviction Released from Incarceration Current Incarceration Convicted of felony on or after 02/07/2014 In compliance with felony conviction? 6 of 14

7 Questions About the People In Your Home Person: Age:69 Prosecution, Custody, Jail, Parole Probation Blind or Disabled Food Assistance or Cash Assistance Disqualification Avoiding Prosecution Probation / Parole Drug Felony Conviction Access to State Benefits Living in a Medical / Nursing Facility Needs to move to Medical / Nursing Facility Released from Incarceration Current Incarceration Housing Assistance Food Assistance LEAP/SSI/OAP/Refugee Medical Assistance Convicted of felony on or after 02/07/2014 In compliance with felony conviction? Job Search Person: Age:34 Prosecution, Custody, Jail, Parole Probation Blind or Disabled Food Assistance or Cash Assistance Disqualification Avoiding Prosecution Probation / Parole Drug Felony Conviction Access to State Benefits Living in a Medical / Nursing Facility Needs to move to Medical / Nursing Facility Released from Incarceration 7 of 14

8 Current Incarceration Housing Assistance Food Assistance LEAP/SSI/OAP/Refugee Medical Assistance Convicted of felony on or after 02/07/2014 In compliance with felony conviction? Job Search Liquid Assets Information Vehicle Asset Information Real Estate Information Burial Asset Information Life Insurance Information Other Asset Questions Person Sold or given away assets (last 5 years)? Sold or given away assets (last 3 months)? Person Sold or given away assets (last 5 years)? Sold or given away assets (last 3 months)? 8 of 14

9 Job Income Information Person: Name of Employer Address of Employer Job Start Date Job end date US ARMY 08/13/ /12/2017 Seasonal? Commission-based? Minister Compensation? Tribal Income? How Often Paid Recent Paycheck Gross Pay Gross Amount Every 2 weeks 10/31/2015 Salary $ Housing Allowance Amount Portion of tribal income from specified sources Hours Actual Annual Amount for 2015 Actual Projected Amount Actual Annual Amount for 2016 $ $ $ One time payment from this Employer Date one time payment received Will income from this source be the same or lower in the calendar year? Job Income Deduction Information In-Kind Income Self-Employment Information Household Tax Information Person Relationships Tax Dependents Joint Filing 9 of 14

10 is the Mother of Tax Deductions Information You told us that no one in your home has Tax Deductions Information WIC Information Currently enrolled in WIC? Want WIC to contact you? Other Job Income Questions Person Left or Lost a Job Other Income Questions Person Grants, Loans or Scholarships Room and Meals Past Employment Other Income Information Past Employment Information Past Employment Past Expenses/Deductions Past Expenses/Deductions 10 of 14

11 Medical Costs Housing Bills Questions Have you paid for any temporary shelter costs (not rent or mortgage) this month? If Yes, what was the amount paid? Does your household get housing or rent assistance? If your household gets Public Housing Assistance, do you get a separate bill for utilities? Room and Meals Expense (Boarders) Person Paying for room and meals? Housing Bills Information Utility Bills Questions Are all utilities included in the rent? Did you get LEAP within the past 12 calendar months? Utility Bills Information Other Bills Questions 11 of 14

12 Person Child or Adult Care Bills Medical Bills Child or Adult Care Bills Child Care Child Support Obligations Other Information Questions Person Medicare Part A, Part B, Part C, or Part D Health Insurance Coverage Health Insurance Previous SSI Benefits SSI Letter? Yes Medicare Information Health Insurance Information Person: Is this policy provided through an employer? How often is the What is the name of the employer? If Lilia pays a premium, how much is it? I don t know How much does the employer contribute to the insurance premium amount? 12 of 14

13 insurance premium amount due for payment? Insurance Company Address Colorado Tell us how the premium is paid. Company Phone Number Insurance Company Name Policy Number Group Number Premium Amount Covered Individuals I don t know Coverage begin date Coverage End Date What is the member ID? What is the name of the health plan? Is your health care provided by an HMO? Is this health insurance a Medicare Supplement Plan? Is this health insurance a Medicare Supplement Plan? Type of coverage TRICARE, Peace Corps, or Other state or federal health program Person: Type Eligible/enrolled in TRICARE Name of Program Eligible for or enrolled in this health coverage in Yes Access to Coverage Enrolled Health Plan Coverage begin date Enrollment End Date Yes 08/13/ /12/2017 Employer Health Coverage Information You told us that no one in your home has Health Coverage. School Enrollment Information Current Employer Sponsored Health Coverage Information You told us that no one in your home has Employer Health Coverage. COBRA, Retiree, Railroad Retirement, or Veteran's Health Plan Information 13 of 14

14 You told us that no one in your home has COBRA, Retiree, or Veteran's Health Plan Information. Electronic Signature By signing this form, I certify that I have reviewed this application; I understand and agree to the Rights, Responsibilities and Penalties and under penalty of perjury, I certify the information I have given is true including the information concerning citizenship and alien status. I have received information on how to apply, what information is available, and what I may need to give the county to help me with getting benefits. By checking this box and typing my name below, I am electronically signing my application. 11/10/2015 7:39 14 of 14