Specific documentation is required to properly screen you and your family for health insurance, charity care and financial assistance programs. There are several documents that can be used for each requirement and documents that are acceptable for one program may not apply to all. We recommend that you bring the document that can be used for every program, if possible, to every appointment. Without the required documents, we will not be able to complete a full screening of all options.
Proof of Identity & Lawful Presence
For Family Medicaid, and CHP+
U.S. Citizens are not required to provide any documentation of their identity and citizenship status, as long as this information can be verified by an electronic system. For the automated verification to occur, we need to have your full name, date of birth, and Social Security Number. Providing certain documents can be used to prove Identity or Lawful Presence and/or help us to be successful with the electronic verification. These documents include, but are not limited to, the following:
- Driver’s License or government-issued Photo ID
- US Passport
- Birth Certificate
- Certificate of Naturalization (DHS forms N-550 or N-570)
- Certificate of US Citizenship (DHS forms N-560 or N-561)
Legal Permanent Residents must provide one of the following:
- Legal Permanent Resident Card
- Employment Authorization Card
- I-94 if a Refugee or Asylee
Proof of Address
CICP & DFAP
The applicant will be asked to provide one of the following:
- Current month and prior month rent receipt, which must include the applicant’s name, the location of the rental property, and the printed name and phone number of the landlord
- Copy of current lease with landlord name and phone number
- Current month mortgage statement
- Current property tax receipt
- One household bill (i.e. water, gas & electricity), paycheck stub, or other income check stub with applicant’s pre-printed name and address from both the current month and the prior month
- Non-household bills (i.e. credit card or cellular phone bills), bank statements, correspondence from a government agency, printed with the applicant’s name and address, or hospital/physician bills will be accepted only if there is evidence that they were mailed to the address, not printed from an electronic source. Current month and prior month required.
Proof of Income for all Responsible Parties in Household
The Documents Listed Below are Required for Certain Programs Only
- Pay stubs from previous/current month of work. Should have at least one month of consecutive pay stubs.
- If no pay stubs are available, then bring a typed letter from your employer on company letterhead showing gross income for previous and current month, how long you have been employed there, actual hours worked per week, pay per hour and pay frequency. (You may also use our employment letter to provide income information.)
- If you are self-employed, bring your business ledgers, mileage sheet(s) and documentation of your business expenses for the previous and current months. Download a printable copy of the Self-Employment Ledger.
- If you have unearned income, you must know the monthly amount.
Other Miscellaneous Documentation
The Documents Listed Below are Required for Certain Programs Only
- Documentation of the value of your assets, i.e. bank statements, Motor Vehicle registrations, and real estate records. Only required for adult Medicaid programs such as Long Term Care.
- Commercial health insurance cards
- One month of receipts for childcare, elderly care, child support, and alimony paid. These items may be used as deductions.
- Bills or receipts for health care costs incurred in the last year that have not been covered by insurance or a health program. These may be used as deductions
- Divorce or separation decree or court-stamped request for divorce or separation