Blank Nevada Division Welfare PDF Template

State of Nevada

Department of Health and Human Services

Division of Welfare and Supportive Services

APPLICATION FOR ASSISTANCE

MEDICAID - MEDICAL ASSISTANCE TO THE AGED, BLIND AND DISABLED (MAABD)

SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP)

IF YOU NEED HELP COMPLETING ANY PART OF THIS FORM, LET US KNOW.

Public Assistance Programs you may apply for:

MEDICAID - Medical Assistance to the Aged, Blind and Disabled (MAABD)

Medical assistance for low-income individuals who are eligible under the following programs:

●Over Age 65

●Blind

●Disabled

●Hospital Stay, Nursing Home Stay, Home Care Waiver Application

●Non-citizens Who Meet Specific Program Requirements

●Qualified Medicare Beneficiaries

SUPPLEMENTAL NUTRITION ASSISTANCE PROGRAM (SNAP)

Food assistance (formerly known as Food Stamps) for low-income households to help supplement the purchase of food.

READ THIS PAGE CAREFULLY BEFORE FILLING OUT THE APPLICATION

1.Read each page carefully and answer every question. If the answer is "none," then write in "NONE."

2.If you need help filling out the form, you may want to ask your family, a friend or a case manager from the Division of Welfare and Supportive Services (DWSS).

3.Remember, you are certifying to the correctness of your answers whether you are completing the form yourself, or acting for another person who is unable to complete the form.

The Division of Welfare and Supportive Services will verify the answers you give on this form. Willful concealment of income and assets could result in criminal prosecution.

4.Your Rights and Obligations as a recipient are attached to the back of this application.

5.If you are applying for someone other than yourself, check boxes or complete blank spaces as it applies to the person for whom the application is made.

2920 – EM (3/11)

If you are also applying for SNAP, we must verify information you provide and take action on your SNAP application within 30 days from the date you submit your application.

If you are eligible, SNAP benefits will be provided from the date you give us the first page.

If you qualify to get SNAP right away, we must take action on your SNAP application within 7 days from the date you give us the first page. You may get SNAP right away if:

Monthly rent/mortgage and utilities are more than your household’s gross monthly income; or Gross monthly income is less than $150 and your household’s resources, such as cash or checking/savings accounts, are $100 or less; or

Disclosure of Social Security Numbers: Pursuant to Title 42 USC 1320b-7, Social Security Numbers (SSN) are required for individuals receiving or seeking to receive assistance for themselves. If you or an individual in your household is applying for assistance and do not wish to provide or apply for an SSN, only this person’s request for assistance will be denied. Undocumented or ineligible non-qualified citizens and other non-applicants or ineligible persons are not required to provide or apply for an SSN. Individuals who do not wish to pursue an SSN are considered non-applicants, but their income and resources may still be countable to other household members seeking assistance such as dependent children and/or a spouse. However, if you or an individual in your household is seeking assistance for themselves and meet “good cause” for not providing or pursuing an SSN, assistance may be granted if otherwise eligible.

Social Security Numbers are used to verify your family’s income and resources and to conduct computer matching with other agencies such as the Social Security Administration, Employment Security Division, Child Support Enforcement Programs and the Internal Revenue Service. It is also used to gather workforce information, investigations, recover overpaid benefits and to ensure duplicate benefits are not issued.

Disclosure of Citizenship and/or Immigration Status: You will be required to provide proof of citizenship and/or immigration status. If you or another member of your family or household do not want SNAP benefits, then you/they DO NOT have to give us information about citizenship or immigration status. If you are applying for TANF-cash assistance, Medicaid or SNAP, we may decide that certain members of your family are ineligible for benefits because they do not have the right immigration status. If that happens, other family members may still be able to get benefits if they are otherwise eligible. If you want us to decide whether other family members are eligible for benefits, you will still need to tell us about their citizenship and/or immigration status. You will also need to tell us about your family’s income and answer the other questions on this form.

Non Discrimination: In accordance with Federal law and U.S. Department of Agriculture (USDA) and Department of Health and Human Services (HHS) policy, this institution is prohibited from discriminating on the basis of race, color, national origin, sex, age, or disability. Under the Food Stamp Act and USDA policy, discrimination is prohibited also on the basis of religion or political beliefs, “To file a complaint of discrimination, contact USDA or HHS. Write USDA, Director, Office of Civil Rights, 1400 Independence Avenue, S.W., Washington D.C. 20250-9410 or call (800) 795-3272 (voice) or (202) 720-6382 (TTY). Write HHS, Director, Office for Civil Rights, Room 506-F, 200 Independence Avenue, S.W., Washington, D.C. 20201 or call (202) 619-0403 (voice) or (202) 619-3257 (TTY). USDA and HHS are equal opportunity providers and employers.”

Important Notice: If you are applying for a child not eligible for Medicaid assistance on this application, the Nevada

√Check Up Program provides low-cost, comprehensive health care coverage to uninsured children 0-18 years of age who are not covered by private insurance or Medicaid. To find out the eligibility requirements for this medical program or to request an application, go to http://nevadacheckup.nv.gov or call 1-877-543-7669.

Medical benefits start from the first day of the month eligibility is approved, with the exception of some Medicare beneficiaries.

Information provided on this form is subject to verification and investigation by federal, state, and local officials. If you make a false or misleading statement, misrepresent, conceal or withhold facts to establish or maintain program eligibility, your benefits may be reduced/denied/terminated. You will be responsible for repayment of all monies, services and benefits for which you were not legitimately entitled.

Individuals found guilty of intentional program violation of SNAP are barred from program participation for twelve (12) months for the first violation, twenty-four (24) months for a second violation and PERMANENTLY for a third violation.

The unlawful use, transfer, acquisition, alteration, or possession of SNAP is punishable by a fine up to $250,000, imprisonment for up to 20 years, or both. You are liable for any over issuance resulting from erroneous information. A court can also bar an individual from the program for an additional 18 months. The person may also be subject to further prosecution under the federal laws.

Qualified non-citizen status will be verified with the Bureau of Citizenship and Immigration Services (BCIS) for eligibility purposes.

I wish payments under the medical insurance program (Part B of Title XVIII) to be made directly to physicians and medical suppliers on any future unpaid bills for medical and other health services furnished me while eligible for welfare assistance.

Eligibility and income information is regularly requested from the Nevada State Employment Security Department, the Social Security Administration and Internal Revenue Service, and is used to determine your eligibility for and amount of assistance.

I hereby assign to the Division of Welfare and Supportive Services, as a condition of eligibility, all rights to medical support or other payments for medical care for myself and all persons for whom I am applying/receiving assistance. I will cooperate with the Division in obtaining third party benefits and/or payments for medical care.

I understand that I have a duty to inform the Division of Welfare and Supportive Services if I, or anyone on my behalf, commence a legal action against someone for recovery of money as reimbursement for medical care and treatment paid by the Medicaid program AND that I must further advise the Division of Welfare and Supportive Services should I, or anyone on my behalf, solicit or receive any offer of settlement of money as reimbursement for medical care and treatment paid for by the Medicaid program. I understand I must surrender any such monies received to the Division of Welfare and Supportive Services.

Medicaid recipients who are: 1) 55 years of age or older; OR 2) inpatients of a medical facility may be responsible for repayment of Medicaid expenditures paid on their behalf. Recovery would be accomplished from the estate of recipient after their death or after the death of their surviving spouse. (See attached Form 6160-AF, Program Operation.)

Any person who signs an application for assistance to the medically indigent and fails to report the following may be personally liable for any money incorrectly paid to the recipient:

1)any required information to the Division of Welfare and Supportive Services which the individual knew at the time they signed the application; or

2)within the period allowed by the Division of Welfare and Supportive Services, any required information to the Division of Welfare and Supportive Services which the individual obtained after filing the application.

I understand, that as a parent of a disabled minor child who receives services under the Medicaid program:

1)I am responsible to contribute to the support of my child by reimbursing the State of Nevada, Division of Welfare and Supportive Services for said services pursuant to NRS 125B.020; and NRS 422.310.

2)I agree to cooperate with the Division of Welfare and Supportive Services and provide to the Division of Welfare and Supportive Services, Medicaid program, all information regarding income, resource and medical insurance, necessary to determine the amount of the reimbursement.

3)I understand if I fail to cooperate or fail to provide the requested information, I will be responsible for a monthly reimbursement payment in the amount of $1,900.

I understand the “period of intended use” for SNAP benefits deposited into an EBT account is 365 days from the date they became available. SNAP benefits left untouched in an EBT account for 365 days will be removed from the account and returned to Food and Nutrition Services (FNS) as required by federal regulations. Federal regulations do allow unused benefits to be applied (credited) to any outstanding SNAP claim (debt) the household may have incurred prior to being returned to FNS. I hereby give the Division of Welfare and Supportive Services permission to apply any unused EBT SNAP benefits to any unpaid or outstanding SNAP debt I or any other adult member of my household owes to the SNAP Program.

(CONTINUED ON NEXT PAGE)

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If I am 60 years of age or older, I hereby consent to the disclosure of my identity and waive my right as an older person to have my identity kept confidential. I hereby release the holder of such information from liability, if any, resulting from the disclosure of the required information.

I understand the questions on this application and the penalty for hiding or giving false information. I agree to notify the Division of Welfare and Supportive Services of any changes in my circumstances that may affect my eligibility for assistance. I understand failure to report changes in circumstances may result in overpayment collection/criminal prosecution.

I understand Social Security Numbers (SSNs) are used to verify income and resources, to see what benefits are available, as case numbers in the computer, gather workforce information for research which helps lawmakers and agencies improve services to Nevadans, investigate fraud, recover overpaid benefits, make sure nobody gets benefits in more than one household (double benefits) or while they are in jail or prison or deceased and match against other federal and state records. For example: Child Support Enforcement Program (CSEP), Unemployment Insurance Benefits (UIB), Internal Revenue Service (IRS), Medicaid and Social Security Administration (SSA), law enforcement/prison records. By signing this application, I allow the agency to use my SSN for the purposes explained on this form. This includes anyone under age 18 I am applying for.

I hereby authorize the Nevada Department of Health and Human Services to make any investigation concerning me or other members of my household which is necessary to determine eligibility for any benefits I have received or will receive under programs administered by the Division of Welfare and Supportive Services. I hereby authorize and consent to the release of all information concerning me and/or my household members to the Department of Health and Human Services by the holder of the information such as, but not limited to, wage information, information made confidential by law, as well as patient information privileged under NRS 49.225, or any other provision of law. This information may also include education records (including IEP records) maintained at the local school district that are necessary for Medicaid reimbursement purposes for health services provided to my child. I hereby release the holder of the information from liability, if any, resulting from the release (disclosure) of the required information. A REPRODUCED COPY OF THIS

AUTHORIZATION LEGALLY CONSTITUTES AN ORIGINAL COPY.

I realize that I must give complete and accurate information and that willful concealment of income and assets could result in criminal prosecution. I certify under penalty of perjury, my answers are correct and complete to the best of my knowledge and ability.

If you are applying for someone else and they are unable to sign, sign your name for them on the applicant's signature line (e.g., John Doe for Mary Doe).

____________________________________________________________________________________________________

WITNESS: (USE IF APPLICANT CANNOT READ OR WRITE OR IS BLIND)

The Information Contained In This Application Has Been Read To The Applicant And I Have Witnessed The Above Signature

____________________________________________________________________________________________________

RECIPIENT'S RIGHTS AND OBLIGATIONS

AS AN APPLICANT/RECIPIENT FOR WELFARE BENEFITS FROM THE STATE OF NEVADA, YOU ARE HEREBY ADVISED THAT:

You have the following RIGHTS:

1.You have the right to a hearing if your application for assistance or services is denied, reduced, terminated, or not acted on with reasonable promptness unless state or federal law requires such action. You may obtain a hearing by mailing in a written request to the Division of Welfare and Supportive Services. You may be represented by legal counsel or by a relative, friend or other spokesperson, or you may represent yourself.

2.The Division of Welfare and Supportive Services provides medical assistance and services without discrimination of any kind (such as race, age, color, religion, sex, disability, handicap [including AIDS and AIDS-related conditions], political belief or national origin) according to federal rules and regulations. When the Division pays another agency, institution or person for services to clients of the Division of Welfare and Supportive Services, the vendor is not permitted to discriminate for any reason (such as race, age, color, religion, sex, disability, handicap [including AIDS and AIDS-related conditions], political belief or national origin) according to federal rules and regulations.

Violations of this provision should be promptly reported to the nearest district office, the Division of Welfare and Supportive Services Administrator, 1470 College Parkway, Carson City, Nevada 89706-7924, (775) 684-0500, the U.S. Office for Civil Rights (OCR), Department of Health and Human Services, 50 United Nations Plaza, San Francisco, California 94102, (415) 437-8310, TDD (415) 437-8311 or toll free 1-800-368-1019 or the Secretary of Agriculture, Washington, D.C. 20250.

3.If you are married and living separate and apart from your spouse, you have the right to enter into a written agreement which equally splits your community income and/or resources between you. If this is done, only the income or resources the agreement specifies as yours will be counted in determining eligibility, unless your spouse makes a portion of his/her income or resources available to you. The portion made available to you will be counted when determining/continuing your eligibility. The written agreement must be specific as to what assets are being divided and how they will be divided between you. It is suggested you consult legal assistance if you decide to enter into such an agreement.

4.When there is a court order dividing community resources, excluding income, between you and your spouse under provisions of 1987 Statutes of Nevada Chapter 123, only these resources awarded to you will be counted in determining/continuing your eligibility unless your spouse makes a portion of his/her resources available to you. The portion made available to you will be counted in determining/continuing your eligibility.

You have the following OBLIGATIONS:

1.Institutionalized persons or persons receiving nursing care at home (includes SSI and non-SSI recipients) may be responsible for paying a portion of their income toward the cost of their care. This is called patient liability. The division district office must be notified immediately of any income changes.

2.All household members must provide proof of their Social Security Number, or their application to obtain a number. The Division of Welfare and Supportive Services’ authority to require Social Security Numbers is Section 1137 of the Social Security Act. The Social Security Number is used to determine and verify eligibility for benefits through such means as computer matching and to prevent and detect fraud and abuse.

3.If you are applying for/receiving Supplemental Security Income (SSI), you must inform your Case Manager immediately of the following:

a.Written proof of your application for SSI (Supplemental Security Income);

b.Proof of your SSI eligibility determination;

c.Termination of SSI;

d.ANY CHANGES IN ADDRESS;

e.Income (if you are institutionalized);

f.Any other changes/information that may affect your eligibility for assistance.

4.If you are NOT receiving Supplemental Security Income (SSI), you must inform your caseworker immediately of the following:

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