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Read and sign this application
Renewal of coverage in future years
Read the following statement and check one box: To make it easier to electronically verify my income at renewal time, I give the
Ohio Department of Medicaid permission to use computer data information from my federal tax returns, provided by the IRS, for the
number of years I checked below. I understand that the Ohio Department of Medicaid will send me the information it has verified and
I will have a chance to correct and update this information. I can also change my mind, at any time, and not allow the Ohio
Department of Medicaid to check this information.
Yes, I give permission to use computer data information from my federal tax returns, provided by the IRS, to electronically verify my
income for (check one box):
5 years (the longest time) 4 years 3 years 2 years 1 year
No, I do not give permission to use my tax returns.
Your rights and responsibilities
- I am signing this renewal form under penalty of perjury which
means I have 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.
- I know that I must tell the Ohio Department of Medicaid if anything
changes (and is different from) what I wrote on this form. I can
call (844) 640-6446 to report any changes within 10 days. I
understand that a change in my information could affect the
eligibility for member(s) of my household.
- I know that under federal law, discrimination is not permitted on
the basis of race, color, national origin, sex, age, sexual
orientation, gender identity, or disability. I can file a complaint of
discrimination by visiting www.hhs.gov/ocr/office/file.
- I understand that the Ohio Department of Medicaid will get
information about my financial resources from banks, credit
unions, or other financial institutions in order to determine my
eligibility for medical assistance. Authorization to get this
information remains in effect until:
• My application for medical assistance is denied; or
• My eligibility for medical assistance ends; or
• I inform the Ohio Department of Medicaid in writing that I
wish to end my authorization.
- If I refuse to authorize the Ohio Department of Medicaid to get
information about me from financial institutions, or I decide to
end my authorization, I understand that my medical assistance
may be denied or discontinued.
If anyone on this application is eligible for Medicaid
- I am giving the Ohio Department of Medicaid our rights to pursue
and get any money from other health insurance, legal
settlements, or other third parties. I am also giving the Ohio
Department of Medicaid our rights to pursue and get medical
support from an ex-spouse or parent.
- I authorize any person who furnishes health care or medical
supplies or services to give the Ohio Department of Medicaid,
the Ohio Department of Job & Family Services, or the Ohio
Department of Health any information related to the extent,
duration, and scope of services provided under the Medicaid
program, WIC, and other medical assistance programs. I also
authorize the previously mentioned departments to exchange
any information I have provided on this form, to enable the
departments to determine my eligibility.
- I understand that if I do not qualify for Medicaid, the Ohio
Department of Medicaid may send my information to another
program so they can see if I qualify.
- The Ohio Department of Medicaid will check my answers using
information from computer data sources, including the Internal
Revenue Service (IRS), the Social Security Administration, the
Department of Homeland Security and others. If the information
does not match, the Ohio Department of Medicaid may ask me to
send more information.
- I understand that, after my death, Ohio Department of Medicaid
can file a claim against my estate to recover money that the state
paid for coverage provided to me. This process must happen if I
am in a medical institution and not expected to return home, or if
I am 55 years of age or older and the state pays for my nursing
facility services, home and community based services, or related
hospital and prescription drug services. The amount recovered
by the Ohio Department of Medicaid will not be more than the
amount Medicaid paid for my care.
- I understand that the Ohio Department of Medicaid is authorized
to collect information on this form, and other supporting
information including Social Security numbers, under the Patient
Protection and Affordable Care Act (Public Law No. 111-148), as
amended by the Health Care Education Reconciliation Act of
2010 (Public Law 111-152) and the Social Security Act.
- Does any child on this renewal form have a parent living outside
of the home?
- If yes, I know I will be asked to cooperate with the agency
that collects medical support from an absent parent. If I think
that cooperating to collect medical support will harm me or
my children, I can tell Medicaid and I may not have to
cooperate.
- I understand that when I send in this form, it means I have
permission from everyone whose information is on the form to
submit their information to Ohio Department of Medicaid and
receive any communications about their eligibility and enrollment.
Yes
No
My right to appeal
If I think that the Ohio Department of Medicaid or the Health
Insurance Marketplace has made a mistake I can appeal its
decision. To appeal means to tell someone at the Ohio Department
of Medicaid or the Health Insurance Marketplace that I think the
action is wrong and ask for a fair review of the action. I know that I
can find out how to appeal by contacting the Ohio Department of
Medicaid at (844) 640-6446. I know that I can be represented in
the process by someone other than myself. My eligibility and other
important information will be explained to me.
Sign and date below. If you want an authorized representative or want to change the authorized representative you have
now, fill out Attachment A on page 10. The last page is a Voter Registration From and is not part of your Medicaid renewal.
If you wish to register to vote, fill that form out and return it separately to your county board of elections.
Check here if you are an authorized representative. Sign below and fill out Attachment A on page 10.
Signature of household contact or authorized representative: Date: