Resume

Mental Health Human Services

Location:

Valley Street, ME, 04102

Salary:

Posted:

April 07, 2024

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Resume:

State of Maine

Department of Health and Human Services (DHHS)

Application For

MaineCare, Food Supplement and

Other Benefits

Application for:

MaineCare – Full Benefits

Low Cost Drugs (DEL) / MaineRx Plus

MaineCare Limited Benefits Program

State SSI Cash Assistance

Medicare Savings Program Only

(Buy In)

Food Supplement Benefits

Do you have a physical or mental health condition that keeps you from working full or part time? Yes No

Providing a Social Security number is optional for individuals who are not applying for coverage in any program.

Your name (first, middle initial, last) Maiden Name Social Security number Sex Birth date (month/day/year) Place of birth Your Medicare claim number (if any) Mailing address:

Street, PO Box, or RR (include apartment number, in care of, etc.) Is this a safe delivery address?

Yes No

City State Zip Code Phone

If different from your mailing address, give the address where you actually live: Were you in foster care and enrolled in the Medicaid program through the State of Maine at age 18, and you are now less than 26 years of age? Yes No If yes, you are not required to complete the income and asset portion of the application in order to qualify for MaineCare.

NOTE: You need to answer only the questions for the program(s) you are applying for. For Food Supplement Benefits Only: To file this application now, we need your name (or that of an authorized representative), address and signature. If eligible, your benefits will begin from the date DHHS gets a signed application. You may be eligible for Food Supplement benefits right away:

does your monthly income and cash/money in a bank add up to less than your monthly living expense?

is your monthly income less than $150 and cash/money in a bank less than $100?

are you a migrant worker and your income has stopped? Social Security numbers are used to do computer matches with I.R.S., BMV, IFW, the Social Security Administration, Department of Labor, other government agencies and private financial institutions. DHHS and federal officials may check with other sources to prove the information you give.

If you give wrong information, you may be charged with giving false information. I understand the questions on this form. I certify, under penalty of perjury, that all my answers are correct and complete as far as I know, including those concerning citizenship and alien status for each person applying for benefits. I understand DHHS has the right to collect from other available insurance or from settlement(s) for accidents or injuries whenever MaineCare pays for Medical Expenses. Signature of person applying Date

Signature of person filling out this form Date

If you have someone who knows your situation, and you want us to contact them to help with this application, please complete the following: Name Address

Telephone

For office use only:

Received 45th day - Residency ID Food Supplement Benefit Expedite Yes No

Return to:

Office for Family

Independence

State of Maine – DHHS

114 Corn Shop Lane

Farmington, ME 04938-9900

For MaineCare and Food Supplement Benefits

ARE YOU:

Married

Widowed

Single

Divorced

Separated

(Check only one box)

If you live with your spouse:

Spouse’s name (first, middle initial, last)

Date of birth Sex Able to work? Yes No

(month /day/year)

Place of birth Maiden name Spouse’s Social Security number

Spouse's Medicare claim number

List other people who live with you and their grade in school if applicable: Last name First name Middle

Initial

Sex Birth -

date

Social Security

Number

(Optional if not

Requesting Coverage)

Relationship

to you

Grade

level

Is everyone you are applying for a U.S. citizen? Yes No If no, please list their names and Alien Registration Numbers. Please list place of birth for each person for whom you are requesting assistance First Name Place of Birth First Name Place of Birth First Name Place of Birth List monthly household income below:

Source Yourself Your spouse

(who lives with you)

Other family members

(please list amount and name of member)

Social Security $ $ $

SSI $ $ $

Other Income or Pensions

(such as railroad retirement, interest,

dividends, etc., please explain)

$ $ $

List household earnings for yourself and your spouse (who lives with you): Please provide the last 4 pay stubs or copies of them (If you are applying for MaineCare only, you are not required to provide verification of earnings at this time, but you may be asked to do so in the future if electronic verification is not possible) Name Employer’s name and

phone number

Gross Amount

earned

How often

are you paid

Hours worked

each week

Is anyone in your household self-employed? Yes No If YES, Who? Source? How often?

Please provide a copy of your most recent tax return or business records. List assets for yourself and your spouse (who lives with you), including jointly owned assets:

(If you are applying for Food Supplement Benefits, also list the assets of others in your household.)

• Checking or Savings Account • Credit Union Shares • IRA, 401K, Keogh • Certificate of Deposit

• Other Accounts

• Profit Sharing • Safety Deposit Box • Assets Owned with Others • Stocks • Annuities • Prepaid Burials • Trusts Name(s) on account Type of asset

(see above)

Name of

bank or institution

Account number Current balance

or value

List life insurance owned by yourself and/or your spouse (who lives with you): Owner Company name and address Face value Cash value Do you or anyone in your household own any land, buildings, time shares or jointly held real estate, including where you live? Yes No If YES, list below:

Owner Type of real estate

Does anyone in your household own any cars, trucks, boats, campers, motorcycles, snowmobiles, ATV’s, trailers, tractors, or other motorized vehicles? Yes No If YES, list below: Year Make Model Owner Used for Amount owed

Did you give away anything in the last 3 months? Yes No Does anyone who is applying have health insurance? Yes Who? ; No Are you requesting help with medical bills incurred within the last three months?

Yes No Which months?

Did you or anyone in your household serve in the U. S. military? Yes No In which branch of the military did you serve? When did you serve? (dates) to Did you serve on foreign soil? Yes No Are you receiving VA benefits that include payment of prescription drugs? Yes No If you are applying for medical coverage, please complete the Medicaid Application Supplement pages at the end of this form.

Estate Recovery:

If you receive benefits from MaineCare after age 55, and certain conditions exist, the Estate Recovery Program will make a claim against the assets of your estate to recover money MaineCare has paid for your care. Estate assets can include real property, including jointly owned property, insurance payments, annuities, any property left to an heir, survivor or assignee. No claim will be made if the only service you receive is the Medicare Buy- In. For more information about the Estate Recovery Program, call MaineCare Member Services at 1-800-***-****.

Please complete a section for each

person applying for benefits. This

information is Voluntary. Your

benefits will not be affected if you do

not answer.

Applicant Second

Person

Third

Person

Fourth

Person

Fifth

Person

Are you Hispanic or Latino?

Are you an American Indian or Alaskan

Native?

Circle the tribe you belong to:

1. Houlton Maliseet 2. Peter Dana Pt.

Passamaquoddy

3. Pleasant Point Passamaquoddy

4. Penobscot 5. Aroostook Micmac

6. Other

Do you live on your tribe’s reservation?

Are you Asian?

Are you Black or African American?

Are you Native Hawaiian or Pacific

Islander?

Are you White?

No Yes

Fill out this section of the form only if you are applying for Food Supplement Benefits Please list your shelter costs (do not list past due amounts or security deposits). Rent How often

Mortgage How often

Property taxes How often

House insurance How often

Condo fees How often

Heat How often

Electricity How often

Telephone (basic) How often

Cooking fuel How often

Water How often

Sewer How often

Trash collection How often

If you rent, is your heat included in your rent? Yes No If you pay a mortgage, are taxes and insurance included in your payment? Yes No Has anyone received HEAP fuel assistance since last October? Yes No Have you moved since last October? Yes No

Have you received help with these expenses from the town or city in the last 6 months? Yes No Does anyone else help pay part or all of these bills? Yes No If yes, who has helped you?

How many people, including yourself, live in your home and purchase and prepare meals with you? Is anyone in your household a migrant or seasonal farm worker? Yes No If anyone in your household is 60 or older or receiving disability benefits, do they pay over $35/month for their medical expenses, such as health insurance (including Medicare), over the counter or prescription medicines, doctor or dentist bills, hearing aids, eye care, transportation and other medical services? Yes No If yes, please list and provide proof of these expenses. Is anyone you are applying for a foster child, in state custody or a boarder Yes No If yes, who? Are you paying someone to care for a child or disabled adult? Yes No Who do you pay? How much do you pay? How often?

Is anyone on strike? Yes No Who?

Has anyone committed an Intentional Program Violation for Food Supplement Benefits Yes No Who? Has anyone quit a job in the last 60 days? Yes No Who? Does anyone pay child support? Yes No Who? How much? How often? To whom? For whom?

Is any household member fleeing to avoid prosecution or jail for a felony or violation of probation or parole? Yes

This institution is prohibited from discriminating on the basis of race, color, national origin, disability, age, sex and in some cases religion or political beliefs.

The U.S Department of Agriculture also prohibits discrimination against its customers, employees, and applicants for employment on the bases of race, color, national origin, age, disability, sex, gender identity, religion, reprisal, and where applicable, political beliefs, marital status, familial or parental status, sexual orientation, or all or part of an individual’s income is derived from any public assistance program, or protected genetic information in employment or in any program or activity conducted or funded by the Department. (Not all prohibited bases will apply to all programs and/or employment activities.) If you wish to file a Civil Rights program complaint of discrimination with USDA, complete the USDA Program Discrimination Complaint Form, found online at http://www.ascr.usda.gov/complaint_filing_cust.html, or at any USDA office, or call 866-***-**** to request the form. You may also write a letter containing all of the information requested in the form. Send your completed complaint form or letter to us by mail at U.S. Department of Agriculture, Director, Office of Adjudication, 1400 Independence Avenue, S.W., Washington, D.C. 20250-9410, by fax 202-***-**** or email at ad4umf@r.postjobfree.com. Individuals who are deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at (800) 877- 8339; or 800-***-**** (Spanish).

For any other information dealing with Supplemental Nutrition Assistance Program (SNAP) issues, persons should either contact the USDA SNAP Hotline Number at 800-***-****, which is also in Spanish or call the State Information/Hotline Numbers (click the link for a listing of hotline numbers by State); found online at http://www.fns.usda.gov/snap/contact_info/hotlines.htm. To file a complaint of discrimination regarding a program receiving Federal financial assistance through the U.S. Department of Health and Human Services (HHS), write: HHS Director, Office for Civil Rights, Room 515-F, 200 Independence Avenue, S.W., Washington, D.C. 20201 or call 202-***-**** (voice) or 800-***-**** (TTY). USDA and HHS are equal opportunity providers and employers. OFI IMS01 (R09-15)

MEDICAID APPLICATION SUPPLEMENT

COMPLETE THIS SUPPLEMENT FOR YOURSELF, YOUR SPOUSE/PARTNER AND CHILDREN WHO LIVE WITH YOU AND/OR ANYONE ON YOUR SAME FEDERAL INCOME TAX RETURN IF YOU FILE ONE. IF YOU DON’T FILE A TAX RETURN, REMEMBER TO STILL ADD FAMILY MEMBERS WHO LIVE WITH YOU.

APP LAST NAME: APP FIRST NAME: MI:

AMERICAN INDIANS AND ALASKA NATIVES

Names of those with Indian Health Service Coverage: Does Not Receive Indian Health Service Coverage, but is eligible: OTHER MEDICAL INSURANCE

(IF APPLICABLE, LIST THE HOUSEHOLD MEMBERS THAT CURRENTLY RECEIVE HEALTH COVERAGE) Name: Company:

Policy: Type:

EMPLOYER INSURANCE

HOUSEHOLD MEMBERS RECEIVING, OR ELIGIBLE FOR, EMPLOYER SPONSORED HEALTH INSUARNCE (NOW OR IN THE NEXT THREE MONTHS) PROVIDING THE SSN IS OPTIONAL FOR PERSONS WHO ARE NOT APPLYING FOR MEDICAL COVERAGE Name: SSN: Minimal essential coverage?

Date when eligible to enroll: Monthly premium for lowest-cost plan offered: $ Employer Name: Employer EIN:

Employer Address:

Employer Phone: Employer Email:

Employer Insurance Name: Employee Contact Info:

TAX INFORMATION, APPLICANT

(YOU CAN STILL BE ELIGIBLE FOR PROGRAMS EVEN IF YOU DON’T FILE FEDERAL INCOME TAX) A. Will you file Income Tax Next Year (if yes, please answer questions A-C; if no, skip to question D: B. Will you file jointly with spouse: Name of spouse: C. Will you claim dependents on your tax return: Name of dependent 1: Name of dependent 2: Name of dependent 3:

D. Will you be claimed as a dependent on someone’s tax return: Name of filer: DEDUCTIONS, APPLICANT

ENTER AMOUNTS FOR ALL THAT APPLY

Alimony paid: How often? Student loan interest: How often? Other deductions: How often? Type:

For American Indians and Alaskan Natives Only

Certain money received can be excluded from income; list any money received from these sources: per capita payments from a tribe that comes from natural resources, usage rights, leases or royalties: payments from natural resources, farming, ranching, fishing, leases, or royalties from land designated as Indian trust land by the Dept. of Interior; and money from selling things that have cultural significance. How much received? $ How often?

SIGNATURE:

I’M SIGNING THIS APPLICATION UNDER PENALTY OF PERJURY WHICH MEANS I’VE PROVIDED TRUE ANSWERS TO ALL THE QUESTIONS ON THIS FORM TO THE BEST OF MY KNOWLEDGE. I KNOW THAT I MAY BE SUBJECT TO PENALTIES UNDER FEDERAL LAW IF I PROVIDE FALSE AND OR UNTRUE INFORMATION.

Signature of applicant:

Date:

v. 11/01/13

TAX INFORMATION, NAME OF PERSON#1 WHO LIVES WITH YOU: A. Will he/she file Income Tax Next Year (if yes, please answer questions A-C; if no, skip to question D: B. Will he/she file jointly with spouse: Name of spouse: C. Will he/she claim dependents on your tax return: Name of dependent 1: Name of dependent 2: Name of dependent 3:

D. Will he/she be claimed as a dependent on someone’s tax return: Name of filer: Total Income (list next year’s total income for this person): DEDUCTIONS, PERSON #1 WHO LIVES WITH YOU – ENTER AMOUNTS FOR ALL THAT APPLY Alimony paid: How often? Student loan interest: How often? Other deductions: How often? Type:

For American Indians and Alaskan Natives Only

TAX INFORMATION, NAMES OF PERSON #2 WHO LIVES WITH YOU: A. Will he/she file Income Tax Next Year (if yes, please answer questions A-C; if no, skip to question D: B. Will he/she file jointly with spouse: Name of spouse: C. Will he/she claim dependents on your tax return: Name of dependent 1: Name of dependent 2: Name of dependent 3:

D. Will he/she be claimed as a dependent on someone’s tax return: Name of filer: Total Income (list next year’s total income for this person): DEDUCTIONS, PERSON #2 WHO LIVES WITH YOU - ENTER AMOUNTS FOR ALL THAT APPLY Alimony paid: How often? Student loan interest: How often? Other deductions: How often? Type:

For American Indians and Alaskan Natives Only

TAX INFORMATION, NAME OF PERSON #3 WHO LIVES WITH YOU: A. Will he/she file Income Tax Next Year (if yes, please answer questions A-C; if no, skip to question D: B. Will he/she file jointly with spouse: Name of spouse: C. Will he/she claim dependents on your tax return: Name of dependent 1: Name of dependent 2: Name of dependent 3:

D. Will he/she be claimed as a dependent on someone’s tax return: Name of filer: Total Income (list next year’s total income for this person): DEDUCTIONS, PERSON #3 WHO LIVES WITH YOU - ENTER AMOUNTS FOR ALL THAT APPLY Alimony paid: How often? Student loan interest: How often? Other deductions: How often? Type:

For American Indians and Alaskan Natives Only

TAX INFORMATION, NAME OF PERSON #4 WHO LIVES WITH YOU: A. Will he/she file Income Tax Next Year (if yes, please answer questions A-C; if no, skip to question D: B. Will he/she file jointly with spouse: Name of spouse: C. Will he/she claim dependents on your tax return: Name of dependent 1: Name of dependent 2: Name of dependent 3:

D. Will he/she be claimed as a dependent on someone’s tax return: Name of filer: Total Income (list next year’s total income for this person): DEDUCTIONS, PERSON #4 WHO LIVES WITH YOU - ENTER AMOUNTS FOR ALL THAT APPLY Alimony paid: How often? Student loan interest: How often? Other deductions: How often? Type:

For American Indians and Alaskan Natives Only

TAX INFORMATION, NAME OF PERSON #5 WHO LIVES WITH YOU: A. Will he/she file Income Tax Next Year (if yes, please answer questions A-C; if no, skip to question D: B. Will he/she file jointly with spouse: Name of spouse: C. Will he/she claim dependents on your tax return: Name of dependent 1: Name of dependent 2: Name of dependent 3:

D. Will he/she be claimed as a dependent on someone’s tax return: Name of filer: Total Income (list next year’s total income for this person): DEDUCTIONS, PERSON #5 WHO LIVES WITH YOU - ENTER AMOUNTS FOR ALL THAT APPLY Alimony paid: How often? Student loan interest: How often? Other deductions: How often? Type:

For American Indians and Alaskan Natives Only

TAX INFORMATION, NAME OF PERSON #6 WHO LIVES WITH YOU: A. Will he/she file Income Tax Next Year (if yes, please answer questions A-C; if no, skip to question D: B. Will he/she file jointly with spouse: Name of spouse: C. Will he/she claim dependents on your tax return: Name of dependent 1: Name of dependent 2: Name of dependent 3:

D. Will he/she be claimed as a dependent on someone’s tax return: Name of filer: Total Income (list next year’s total income for this person): DEDUCTIONS, PERSON #6 WHO LIVES WITH YOU - ENTER AMOUNTS FOR ALL THAT APPLY Alimony paid: How often? Student loan interest: How often? Other deductions: How often? Type:

For American Indians and Alaskan Natives Only

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