Program Branch

Case name

SSNPrime # App status

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Office use

ReceivedFor date stamp code only

Date of request

Application for Oregon Health Plan and Healthy Kids

About you. Please tell us about yourself, even if you are only applying for benefits for your children. You may need to send proof of immigration status or tribal affiliation if you are applying for yourself (see the checklist on page 16).

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Read this before you start.

• This is for the Oregon Health Plan and Healthy Kids. You can apply for one or both programs with this application.

• Please answer all questions so we have the information we need to see if you qualify.

• Read the Green Booklet by clicking here. It includes more information about the questions asked.

When you see this arrow, it means you may have to send documents that show us the information you gave is correct. Please mail copies of these documents along with your application to:

OHP Processing Center, PO Box 14520, Salem, OR 97309-5044

or fax to 503-373-7493

You can get this application in other formats.

• This document can be provided upon request in alternative formats for individuals with disabilities. Other formats may include (but are not limited to) large print, Braille, audio recordings, Web-based communications and other electronic formats. Email altformat.app@state.or.us, or call 1-800-699-9075 (voice) or TTY 711 to arrange for the alternative format that will work best for you.

• You can get this application in another language or you can get an interpreter. Call 1-800-699-9075 or TTY 711.

This section is for the office. Please continue the application on the next page.

Name (first, middle initial, last) Sex female male

OHP Drawing entry number (if you have one)

Phone (required) Email

Date of birth (month, day, year)

City (mailing address) State ZIP code (required)Mailing address (if not your home address) Apartment #

Are you a U.S. citizen? Yes No If no, and you have an Alien Resident number, write it here:

Are you applying for health coverage for yourself? Yes No If yes, you must tell us about citizenship and Social Security or immigration status:

Home address Apartment # City (home address) State ZIP code (required)

For more information about:• Healthy Kids or to find local application assistance,

click here: www.oregonhealthykids.gov • Oregon Health Plan, click here:

www.oregon.gov/OHA/healthplan

City of birth State of birth Maiden or birth name

Social Security number: If you do not have a Social Security number, check this box:

Your answers to these questions help us, but you can choose not to answer.

Are you an Alaska Native or a member of a federally recognized American Indian tribe? Yes No Do you receive services through Indian Health Services or could you? Yes No

Ethnicity Hispanic/Latino Not Hispanic/Latino Race (choose one or more) American Indian or Alaska Native Asian Black or African American Native Hawaiian or other Pacific Islander White

Case # Worker ID

Need help? Please call 1-800-699-9075 (TTY 711). Monday to Friday 7 a.m. to 6 p.m.?

People who live in your home. Please tell us about everyone (other than the person listed in Question 1) in your home. See the Green Booklet for more information. You may need to send proof of immigration status or tribal affiliation for each person applying for benefits (see the checklist on page 16).

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Person 1 Name (first, middle initial, last) Are you applying for health coverage for this person? Yes No

Sex female male

Date of birth (month, day, year)State of birthCity of birth Maiden or birth name

Your answers to these questions help us, but you can choose not to answer.

Ethnicity Hispanic/Latino Not Hispanic/Latino Race (choose one or more) American Indian or Alaska Native Asian Black or African American Native Hawaiian or other Pacific Islander White

Is this person an Alaska Native or a member of a federally recognized American Indian tribe? Yes No

Does this person receive services through Indian Health Services now or could this person receive services? Yes No

Is this person a U.S. citizen? Yes No If no, and this person has an Alien Resident number, write it here:

This is my husband or wife child stepchild other:

If you are applying for this person, you must tell us about citizenship and Social Security:

Social Security number:

Person 2 Name (first, middle initial, last) Are you applying for health coverage for this person? Yes No

Sex female male

Date of birth (month, day, year)State of birthCity of birth Maiden or birth name

Is this person a U.S. citizen? Yes No If no, and this person has an Alien Resident number, write it here:

This is my husband or wife child stepchild other:

If you are applying for this person, you must tell us about citizenship and Social Security:

Social Security number:

Person 3 Name (first, middle initial, last) Are you applying for health coverage for this person? Yes No

Sex female male

Date of birth (month, day, year)State of birthCity of birth Maiden or birth name

Is this person a U.S. citizen? Yes No If no, and this person has an Alien Resident number, write it here:

This is my husband or wife child stepchild other:

If you are applying for this person, you must tell us about citizenship and Social Security:

Social Security number:

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Your answers to these questions help us, but you can choose not to answer.

Ethnicity Hispanic/Latino Not Hispanic/Latino Race (choose one or more) American Indian or Alaska Native Asian Black or African American Native Hawaiian or other Pacific Islander White

Is this person an Alaska Native or a member of a federally recognized American Indian tribe? Yes No

Does this person receive services through Indian Health Services now or could this person receive services? Yes No

Your answers to these questions help us, but you can choose not to answer.

Ethnicity Hispanic/Latino Not Hispanic/Latino Race (choose one or more) American Indian or Alaska Native Asian Black or African American Native Hawaiian or other Pacific Islander White

Is this person an Alaska Native or a member of a federally recognized American Indian tribe? Yes No

Does this person receive services through Indian Health Services now or could this person receive services? Yes No

If this person does not have a Social Security number, check this box:

If this person does not have a Social Security number, check this box:

If this person does not have a Social Security number, check this box:

OHA 7210W (Rev 6/12)

? Need help? Please call 1-800-699-9075 (TTY 711). Monday to Friday 7 a.m. to 6 p.m.

People who live in your home (continued). Please tell us about everyone (other than the person listed in Question 1) in your home. See the Green Booklet for more information. You may need to send proof of immigration status or tribal affiliation for each person applying for benefits (see the checklist on page 16).

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Person 4 Name (first, middle initial, last) Are you applying for health coverage for this person? Yes No

Sex female male

Date of birth (month, day, year)State of birthCity of birth Maiden or birth name

Is this person a U.S. citizen? Yes No If no, and this person has an Alien Resident number, write it here:

This is my husband or wife child stepchild other:

If you are applying for this person, you must tell us about citizenship and Social Security:

Social Security number:

Person 5 Name (first, middle initial, last) Are you applying for health coverage for this person? Yes No

Sex female male

Date of birth (month, day, year)State of birthCity of birth Maiden or birth name

Is this person a U.S. citizen? Yes No If no, and this person has an Alien Resident number, write it here:

This is my husband or wife child stepchild other:

If you are applying for this person, you must tell us about citizenship and Social Security:

Social Security number:

Person 6 Name (first, middle initial, last) Are you applying for health coverage for this person? Yes No

Sex female male

Date of birth (month, day, year)State of birthCity of birth Maiden or birth name

Is this person a U.S. citizen? Yes No If no, and this person has an Alien Resident number, write it here:

This is my husband or wife child stepchild other:

If you are applying for this person, you must tell us about citizenship and Social Security:

Social Security number:

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Your answers to these questions help us, but you can choose not to answer.

Ethnicity Hispanic/Latino Not Hispanic/Latino Race (choose one or more) American Indian or Alaska Native Asian Black or African American Native Hawaiian or other Pacific Islander White

Is this person an Alaska Native or a member of a federally recognized American Indian tribe? Yes No

Does this person receive services through Indian Health Services now or could this person receive services? Yes No

Your answers to these questions help us, but you can choose not to answer.

Ethnicity Hispanic/Latino Not Hispanic/Latino Race (choose one or more) American Indian or Alaska Native Asian Black or African American Native Hawaiian or other Pacific Islander White

Is this person an Alaska Native or a member of a federally recognized American Indian tribe? Yes No

Does this person receive services through Indian Health Services now or could this person receive services? Yes No

Your answers to these questions help us, but you can choose not to answer.

Ethnicity Hispanic/Latino Not Hispanic/Latino Race (choose one or more) American Indian or Alaska Native Asian Black or African American Native Hawaiian or other Pacific Islander White

Is this person an Alaska Native or a member of a federally recognized American Indian tribe? Yes No

Does this person receive services through Indian Health Services now or could this person receive services? Yes No

Use Extra Form A on page 9 if you need to tell us about more than 6 other people in your home.

If this person does not have a Social Security number, check this box:

If this person does not have a Social Security number, check this box:

If this person does not have a Social Security number, check this box:

OHA 7210W (Rev 6/12)

Need help? Please call 1-800-699-9075 (TTY 711). Monday to Friday 7 a.m. to 6 p.m.?

Pregnancy. Please tell us about anyone in your home (related to you or your children) who is pregnant. You must send proof. Please send a copy of a letter from a doctor or clinic saying this person is pregnant.

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Name Due date (month, day, year)Person 1 Does the baby’s father live in your home? Yes No What is his name?

Name Due date (month, day, year)Person 2 Does the baby’s father live in your home? Yes No What is his name?

Use the space on page 15 if you need to tell us about more people who are pregnant.

Please tell us about anyone in your home (related to you or your children, and 16 years or older) who is in high school, college, or technical or vocational school. We will contact you if we need proof.

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Name School namePerson 1 Does the school consider this student full time part time

Name School namePerson 2 Does the school consider this student full time part time

Name School namePerson 3 Does the school consider this student full time part time

Use the space on page 15 if you need to write about more people who are in school.

Absent parents. Answer if you are applying for any child under age 19 (including expected children) whose parents are absent. Absent parents are parents who do not live in the household, including parents who are in jail. Use Extra Form B on page 10 if you need to write about more than 2 absent parents.

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Social Security number (if you know it)

Name (first, middle initial, last)

AddressSex female male

StateCity

Hours each week this parent spends with the child:

Date this parent stopped living with the child (month, day, year)

List this parent’s children if you have included those children on this application.

Date of birth (month, day, year)

This is my spouse or ex-spouse partner or ex-partner child stepchild other:

Absent parent 1

Can the child or children get health insurance through this parent? Yes No I don’t know

If this is an absent father, has paternity been legally established? Yes No I don’t know

Do you think this parent might hurt you or the child if we try to find out about paternity or health insurance? Yes No

ZIP code

Social Security number (if you know it)

Name (first, middle initial, last)

AddressSex female male

StateCity

Hours each week this parent spends with the child:

Date this parent stopped living with the child (month, day, year)

List this parent’s children if you have included those children on this application.

Date of birth (month, day, year)

This is my spouse or ex-spouse partner or ex-partner child stepchild other:

Absent parent 2

Can the child or children get health insurance through this parent? Yes No I don’t know

If this is an absent father, has paternity been legally established? Yes No I don’t know

Do you think this parent might hurt you or the child if we try to find out about paternity or health insurance? Yes No

ZIP code

4 Does your partner or spouse make you afraid by yelling or physically hurting you or your children? Yes No See page 13 of the Green Booklet for more information.

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4OHA 7210W (Rev 6/12)

? Need help? Please call 1-800-699-9075 (TTY 711). Monday to Friday 7 a.m. to 6 p.m.

Money from work. Please tell us about wages, salaries, and commissions for this month from jobs. We need to know about money that has already been paid or that will be paid this month to anyone in your home who is related to you or your children (including expected children). Use gross income (totals before taxes and deductions).

You must send proof. Please send a copy of the most recent pay stub, or a paystub received within the last 30 days, for each job listed.

Does anyone in your home get money for working? Yes No If yes, fill out this page.

Self-employment means you are being paid for doing work, but you don’t have a regular employer other than yourself who gives you a paycheck and takes out taxes. Perhaps you have your own company with a separate bank account, or perhaps you do odd jobs for people who pay you in cash.

Does anyone in your home get money for self-employment? Yes No If yes, write about self-employment on Extra Form C on page 11.

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Write about the month that includes the day on which you are applying. For example, if you are applying on September 30th, write about September. Or, if you are applying on October 1st, write about October. Use your best guess for what the totals will be.

Write the name of this month:

If any income has recently changed or will be changing in the next month or two, please let us know why (for example, “I just lost my job,” or “My hours at work have been cut.”). If your income is going to be less, please let us know what you expect your gross income (before taxes and deductions) to be next month.

Who earns money from this job?

Does this job pay hourly? Yes No If yes, how much each hour? $

How much gross income will this job pay this month? $

Job 1 What person, business, or agency pays this person?

How many hours each week?

This job pays: every week every 2 weeks every month

Who earns money from this job?

Does this job pay hourly? Yes No If yes, how much each hour? $

How much gross income will this job pay this month? $

Job 2 What person, business, or agency pays this person?

How many hours each week?

This job pays: every week every 2 weeks every month

Who earns money from this job?

Does this job pay hourly? Yes No If yes, how much each hour? $

How much gross income will this job pay this month? $

Job 3 What person, business, or agency pays this person?

How many hours each week?

This job pays: every week every 2 weeks every month

Who earns money from this job?

Does this job pay hourly? Yes No If yes, how much each hour? $

How much gross income will this job pay this month? $

Job 4 What person, business, or agency pays this person?

How many hours each week?

This job pays: every week every 2 weeks every month

Use the space on page 15 if you need to tell us about more money from work.

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5OHA 7210W (Rev 6/12)

Need help? Please call 1-800-699-9075 (TTY 711). Monday to Friday 7 a.m. to 6 p.m.?

Does anyone in your home get money from places other than work? Yes No If yes, tell us about this month’s income for anyone in your home who is related to you or your children (including expected children). You must send proof (see the checklist on page 16).

Tell us about money, including:• rent paid to you• loans repaid to you• TANF (Temporary Assistance for

Needy Families)• retirement pension• veterans benefits

• worker’s compensation• disability benefits• child or spousal support• guardian or foster care payments• Social Security benefits• Supplemental Security Income (SSI)

• dividends or interest on investments• tribal payments• unemployment compensation• educational income (such as financial aid)• other:

Who gets this income?

What person, business, or agency pays this person? How often? every week every 2 weeks every month

1st kind of income from list above

How much this month? $

Write the kind of income here.

Who gets this income?

What person, business, or agency pays this person? How often? every week every 2 weeks every month

2nd kind of income from list above

How much this month? $

Write the kind of income here.

Who gets this income?

What person, business, or agency pays this person? How often? every week every 2 weeks every month

3rd kind of income from list above

How much this month? $

Write the kind of income here.

Use the space on page 15 if you need to tell us about more money from other places.

Resources. Tell us about resources that belong to anyone in your home who is related to you or your children (including expected children), including:

• checking accounts• savings accounts

• cash• certificates of deposit

• stocks and bonds• IRAs and 401(k)s

This resource belongs to:Kind of resourceResource 1 Value $

This resource belongs to:Kind of resourceResource 2 Value $

This resource belongs to:Kind of resourceResource 3 Value $

Use the space on page 15 if you need to tell us about more resources.

9

Vehicles and other property. Tell us about all vehicles, such as cars, trucks, or motorcycles, and other property, such as land or buildings, that belong to anyone in your home who is related to you or your children (including expected children).

Use the space on page 15 if you need to tel us about more vehicles or other property.

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Model yearVehicle 1 How much is it worth? $

How much is it worth? $

Model make

Model yearVehicle 2 Model make

Kind of propertyOther property 1Do not include the home you live in.

Kind of propertyOther property 2Do not include the home you live in.

How much is still owed? $

How much is still owed? $

How much is still owed? $

How much is still owed? $

Who owns this property?

Who owns this property?

Who owns this vehicle?

Who owns this vehicle?

How much is it worth? $

How much is it worth? $

OHA 7210W (Rev 6/12)

? Need help? Please call 1-800-699-9075 (TTY 711). Monday to Friday 7 a.m. to 6 p.m.

You can name an authorized representative. This person can give or get information about your case, and can sign your application. You do not need to list people already listed on this form. See page 19 of the Green Booklet for more information.

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Name of authorized representative (first, middle initial, last) Phone number

You can name a person to whom we can release information. This person can give or get information about your case, but cannot sign your application. You do not need to list people already listed on this form. See page 19 of the Green Booklet for more information.

13

Name (first, middle initial, last) Phone number

Is someone helping you fill out this application? Yes No

If yes, please tell us about the person helping you.15

Name (first, middle initial, last) Phone number

This person is my: authorized representative legal guardian attorney in fact Healthy Kids grantee or assister OHP outreach and enrollment worker other:

Does anyone 18 years or younger who you want medical coverage for have a disability, a kidney disorder, or a condition that, without treatment, would be life-threatening or cause permanent loss of function or disability?

Yes No If yes, who?

If anyone 19 years or older who you want medical coverage for has a kidney disorder or a serious disability that prevents them from working, please fill out Extra Form D on page 12.

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16 If you speak a primary language other than English, please list it here:

Do you want future information in this other language or in another format? Yes No

See page 1 of this application or the cover of the Green Booklet for formats.

Please tell us which format you would prefer:

Does anyone in your home (related to you or your children) who is 19 years or older have health insurance now, or did they in the last 6 months? Yes No

Does anyone in your home (related to you or your children) who is 18 years or younger have health insurance now, or did they in the last 2 months? Yes No

If yes to one or both of these questions, please fill out Extra Form E on pages 13 and 14.

12

Coverage within the last 2 months was through COBRA Yes No If yes, who?

Coverage was lost because a parent lost a job, had their hours reduced, or it was no longer offered through work Yes No If yes, who?

Coverage within the last 2 months was through OMIP, FMIP, or Family Health Insurance Assistance Program Yes No If yes, who?

Coverage within the last 2 months was through Kaiser Permanente Child Health Insurance or Kaiser Transition Program Yes No If yes, who?

Is anyone in your home who is applying for benefits able to get insurance through an employer? Yes No If yes, who?

OHA 7210W (Rev 6/12)

Need help? Please call 1-800-699-9075 (TTY 711). Monday to Friday 7 a.m. to 6 p.m.?

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Choosing a plan. There may be a Coordinated Care Organization, or CCO, available in your community. CCOs are local networks of doctors, mental health providers, hospitals and other providers. They work together for patient-centered care for people on the Oregon Health Plan and Healthy Kids. See pages 20– 23 of the Green Booklet for more information.

• ReadmoreaboutCCOsatwww.health.oregon.gov.

We encourage you to choose a CCO and dental plan or a medical and dental plan. If you don’t make a choice, we may choose for you. Before you pick, you might want to ask your doctor and dentist which plans they accept. Read the list of plans at www.oregon.gov/dhs/healthplan.

Write your first and second choices for CCOs and dental or medical and dental plans below. Sometimes the first choice is full. Depending on which program your children qualify for, we may send you a letter asking you to choose another medical plan.

CCO - 1st choice CCO - 2nd choice

Dental plan - 1st choice Dental plan - 2nd choice

American Indians and Alaska Natives who want to be enrolled in plans. American Indians, Alaska Natives and people who have access to care through Indian Health Services may choose to enroll into a Coordinated Care Organization (CCO) or a managed care plan where available. You may also choose to be enrolled in a dental and/or mental health plan only. If you are enrolled in a CCO or a managed care plan, you can still access services at Indian Health Services, the Urban Indian Program or through the Tribal Health Clinic.

• IfAmericanIndianorAlaskaNativeandyouchoosetoenrollinplans,usetheboxesabove to write your plan choices.

• IfAmericanIndianorAlaskaNativeandyouchoosenottoenrollinaplan,usethelinesbelow. List who does not want to be enrolled in a medical plan, dental plan, mental health plan or Coordinated Care Organization:

These people do not want to be enrolled in a Medical Plan:

Name(s) _________________________________________________________________________________

These people do not want to be enrolled in a Dental Plan:

Name(s) _________________________________________________________________________________

These people do not want to be enrolled in a Mental Health Plan:

Name(s) _________________________________________________________________________________

These people do not want to be enrolled in a Coordinated Care Organization:

Name(s) _________________________________________________________________________________

If you don’t enroll in a plan, you will be covered by an open card that allows you to get care through Indian Health Services, Tribal Health Clinics and other providers based on your area. You can let your worker know at anytime if you decide you would like to be enrolled into a plan.

Medical plan - 1st choice Medical - 2nd choice

Dental plan - 1st choice Dental plan - 2nd choice

OR

OHA 7210W (Rev 6/12)

Need help? Please call 1-800-699-9075 (TTY 711). Monday to Friday 7 a.m. to 6 p.m.? page

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Extra Forms A, B, C, D, and E are on the next 6 pages. Please read through each form and complete the ones that you need to fill out. Sign and submit this application on page 18.

A People. If you have filled out Part 2 of the application and need more space to tell us about everyone in your home, use this form.

Extra Form A: People in Your Home

Person 7 Name (first, middle initial, last) Are you applying for health coverage for this person? Yes No

Sex female male

Date of birth (month, day, year)State of birthCity of birth Maiden or birth name

Is this person a U.S. citizen? Yes No If no, and this person has an Alien Resident number, write it here:

This is my husband or wife child stepchild other:

If you are applying for this person, you must tell us about citizenship and Social Security:

Social Security number:

Your answers to these questions help us, but you can choose not to answer.Ethnicity Hispanic/Latino Not Hispanic/Latino Race (choose one or more) American Indian or Alaska Native Asian Black or African American Native Hawaiian or other Pacific Islander White

Is this person an Alaska Native or a member of a federally recognized American Indian tribe? Yes No Does this person receive services through Indian Health Services now or could this person receive services? Yes No

Use the space on page 15 if you need to tell us about more people in your home.

Person 8 Name (first, middle initial, last) Are you applying for health coverage for this person? Yes No

Sex female male

Date of birth (month, day, year)State of birthCity of birth Maiden or birth name

Is this person a U.S. citizen? Yes No If no, and this person has an Alien Resident number, write it here:

This is my husband or wife child stepchild other:

If you are applying for this person, you must tell us about citizenship and Social Security:

Social Security number:

Your answers to these questions help us, but you can choose not to answer.Ethnicity Hispanic/Latino Not Hispanic/Latino Race (choose one or more) American Indian or Alaska Native Asian Black or African American Native Hawaiian or other Pacific Islander White

Is this person an Alaska Native or a member of a federally recognized American Indian tribe? Yes No Does this person receive services through Indian Health Services now or could this person receive services? Yes No

Person 9 Name (first, middle initial, last) Are you applying for health coverage for this person? Yes No

Sex female male

Date of birth (month, day, year)State of birthCity of birth Maiden or birth name

Is this person a U.S. citizen? Yes No If no, and this person has an Alien Resident number, write it here:

This is my husband or wife child stepchild other:

If you are applying for this person, you must tell us about citizenship and Social Security:

Social Security number:

Your answers to these questions help us, but you can choose not to answer.Ethnicity Hispanic/Latino Not Hispanic/Latino Race (choose one or more) American Indian or Alaska Native Asian Black or African American Native Hawaiian or other Pacific Islander White

Is this person an Alaska Native or a member of a federally recognized American Indian tribe? Yes No Does this person receive services through Indian Health Services now or could this person receive services? Yes No

If this person does not have a Social Security number, check this box:

If this person does not have a Social Security number, check this box:

If this person does not have a Social Security number, check this box:

OHA 7210W (Rev 6/12)

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B Absent parents. If you have filled out Part 6 of the application and need space to tell us about other absent parents, use this form.

Extra Form B: Absent Parents

Social Security number (if you know it)

Name (first, middle initial, last)

AddressSex female male

StateCity

Hours each week this parent spends with the child:

Date this parent stopped living with the child (month, day, year)

List this parent’s children if you have included those children on this application.

Date of birth (month, day, year)

This is my spouse or ex-spouse partner or ex-partner child stepchild other:

Absent parent 3

Can the child or children get health insurance through this parent? Yes No I don’t know

If this is an absent father, has paternity been legally established? Yes No I don’t know

Do you think this parent might hurt you or the child if we try to find out about paternity or health insurance? Yes No

ZIP code

Social Security number (if you know it)

Name (first, middle initial, last)

AddressSex female male

StateCity

Hours each week this parent spends with the child:

Date this parent stopped living with the child (month, day, year)

List this parent’s children if you have included those children on this application.

Date of birth (month, day, year)

This is my spouse or ex-spouse partner or ex-partner child stepchild other:

Absent parent 4

Can the child or children get health insurance through this parent? Yes No I don’t know

If this is an absent father, has paternity been legally established? Yes No I don’t know

Do you think this parent might hurt you or the child if we try to find out about paternity or health insurance? Yes No

ZIP code

Social Security number (if you know it)

Name (first, middle initial, last)

AddressSex female male

StateCity

Hours each week this parent spends with the child:

Date this parent stopped living with the child (month, day, year)

List this parent’s children if you have included those children on this application.

Date of birth (month, day, year)

This is my spouse or ex-spouse partner or ex-partner child stepchild other:

Absent parent 5

Can the child or children get health insurance through this parent? Yes No I don’t know

If this is an absent father, has paternity been legally established? Yes No I don’t know

Do you think this parent might hurt you or the child if we try to find out about paternity or health insurance? Yes No

ZIP code

Use the space on page 15 if you need to tell us about more absent parents.

OHA 7210W (Rev 6/12)

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11

Business name (if there is one)

What does this business do?

Business address City State Business phone number

Is this business incorporated? Yes No

Tell us about this business and income from self-employment.

Gross income this month (before expenses)

$

C Is anyone in your home self-employed? Yes No If yes, fill out this form.

Send all available proof of income and expenses for the most recent month available (see the checklist on page 16).

Self-employment means you are being paid for doing work, but you don’t have a regular employer other than yourself who gives you a paycheck and takes out taxes. Perhaps you have your own company with a separate bank account, or perhaps you do odd jobs for people who pay you in cash.

Extra Form C: Self-Employment

• business property (rent, taxes and assessments, utilities, interest on mortgage, insurance premiums)

• equipment (services, repair and rental of business equipment, taxes and assessments)

• professional fees, legal fees, licenses and permits (such as book-keeper, attorney)

• operating supplies (such as stationery, postage, cleaning supplies)• repairs to business equipment or motor vehicles

• advertising (such as newspaper ads, business cards, signs, flyers)• interest paid on business loans• telephone for business• travel (20 cents per mile. Do not count commuting costs.)• cost of materials purchased for resale (such as cosmetic products.

For newspaper carriers, include the cost of newspapers, bags, and rubber bands.)

• cost of materials used to make a product

Tell us about your business expenses. Here is a list of many kinds of expenses. Please tell us about your business expenses, whether or not they are on the list.

1st business expense How much this month? $

Kind of expense

2nd business expense How much this month? $

Kind of expense

3rd business expense How much this month? $

Kind of expense

4th business expense How much this month? $

Kind of expense

5th business expense How much this month? $

Kind of expense

6th business expense How much this month? $

Kind of expense

7th business expense How much this month? $

Kind of expense

8th business expense How much this month? $

Kind of expense

9th business expense How much this month? $

Kind of expense

10th business expense How much this month? $

Kind of expense

Use the space on page 15 if you have more expenses.

Is your office located within your home? Yes No

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D Do any adults (19 or older) for whom you are applying have a mental or physical disability or kidney disorder? Yes No If yes, fill out this form.

Person 1

Person 2

Tell us about any adult (19 or older) in your home who has end-stage renal disease, has regular dialysis, or who has had a kidney transplant in the past 3 years.

Tell us about this person’s disability or medical condition.

Tell us about this person’s disability or medical condition.

Person 1

Person 2

Have you applied for disability benefits through the Social Security Administration (SSA) for this disability? Yes No If yes, and you got a decision letter, tell us:

Have you applied for disability benefits through the Social Security Administration (SSA) for this disability? Yes No If yes, and you got a decision letter, tell us:

Has this disability lasted more than 1 year? Yes No

Has this disability lasted more than 1 year? Yes No

Will this disability last more than 1 year? Yes No

Will this disability last more than 1 year? Yes No

Your application was approved denied

Your application was approved denied

Date of your application (month, year)

Date of your application (month, year)

When did you get a decision letter? (month, year)

When did you get a decision letter? (month, year)

If your application was denied

If your application was denied

Did you appeal? Yes No

Did you appeal? Yes No

Has the disability gotten worse since you were denied benefits? Yes No

Has the disability gotten worse since you were denied benefits? Yes No

If yes, what was the appeal date? (month, year)

If yes, what was the appeal date? (month, year)

If yes, when did the disability get worse? (month, year)

If yes, when did the disability get worse? (month, year)

Tell us how it got worse:

Tell us how it got worse:

Is there a new medical condition since you were denied benefits? Yes No

Is there a new medical condition since you were denied benefits? Yes No

If yes, when did it start? (month, year)

Tell us about the new condition:

If yes, when did it start? (month, year)

Tell us about the new condition:

Extra Form D: Disability or Kidney Disorder

Name

Name

Name

Name

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more on the next page

E

Extra Form E: Other Insurance

Have active insurance Insurance is paid for privately Insurance is through COBRA Insurance has changed Insurance is from an employer Date insurance is or was no longer available ___/___/____

If you pay for all or part of your insurance, we may be able to reimburse you. For more information, see Section 5 on the next page.

Section 2: Status of insurance – check all that apply

Please note: Many medical programs allow you to have other insurance and still qualify for medical benefits from the state.

Office Use Only

Program Branch Worker ID Case Number

Case Name

TPL / Good cause coding

0 1 2 3 4 5 6 7 Rush Processing | Reason:

List all people covered by Policy 1 who are applying for or receiving medical benefits.

Applicant or client namePerson 1 Prime number (Office use only)Date of birth (month, day, year)

Applicant or client namePerson 2 Prime number (Office use only)Date of birth (month, day, year)

Applicant or client namePerson 4 Prime number (Office use only)Date of birth (month, day, year)

Applicant or client namePerson 5 Prime number (Office use only)Date of birth (month, day, year)

Applicant or client namePerson 3 Prime number (Office use only)Date of birth (month, day, year)

* The policy holder is the owner of the insurance policy.

Date of birth (month, day, year)

Policy ID Number

Social Security number

Section 3: Policy 1 information

Type of policy (check all that apply): Medical Dental Pharmacy Vision Other:

Policy holder’s* name (first, middle initial, last)

Insurance company

Section 1

Does anyone in your home (related to you or your children) have employer-sponsored or privately paid health insurance or have they had it recently? This would include medical, dental, vision, pharmacy, long-term care, accident, student, or other types of health insurance policies. Yes No

If yes, fill out this form. Send copies of the front and back of insurance cards.

If you are applying for adults (age 19 or older), we need this information for the past 6 months. If you are applying for children (age 18 or younger), we need this information for the past 2 months.

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List all people covered by Policy 2 who are applying for or receiving medical benefits.

Applicant or client namePerson 1 Prime number (Office use only)Date of birth (month, day, year)

Applicant or client namePerson 2 Prime number (Office use only)Date of birth (month, day, year)

Applicant or client namePerson 4 Prime number (Office use only)Date of birth (month, day, year)

Applicant or client namePerson 5 Prime number (Office use only)Date of birth (month, day, year)

Applicant or client namePerson 3 Prime number (Office use only)Date of birth (month, day, year)

* The policy holder is the owner of the insurance policy.

Date of birth (month, day, year)

Policy ID Number

Social Security number

Section 4: Policy 2 information

Type of policy (check all that apply): Medical Dental Pharmacy Vision Other:

Policy holder’s* name (first, middle initial, last)

Insurance company

Please return this completed form and copies of your insurance cards (front and back) with your application. Let us know in the space above if you do not have your insurance cards.

In some cases, the state’s Health Insurance Premium Payment (HIPP) program may reimburse people who pay for employer-sponsored or private major medical health insurance if it is cost-effective for the state.

Do you pay for all or part of your private or employer-sponsored health insurance premium? Yes No

If you answered yes, we will contact you and ask for more information to see if you qualify for this type of premium reimbursement.

Section 5: Possible premium reimbursement

Section 6: Use this section for any additional information you want to provide about your current or recent insurance coverage.

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Room for more information. If you ran out of room on any of the questions, please use this area to give us that information. Be sure to tell us what question you are answering and answer all parts of the original question.

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Your checklist.19

I printed a copy of the application and all proof needed for my records. (Print this form before hitting the ‘submit’ button on page 18.)

I looked at Extra Forms (A, B, C, D, and E) and completed the ones that I needed to fill out.

• Include your Alien Resident number and Social Security number on the application (if you have one or both). AND

•Send a copy of your immigration card/green card or copies of immigration legal papers.

•You do not need to be a U.S. citizen to apply for medical benefits for yourself or your children.

Immigration status. If you are not a U.S. citizen and are applying for benefits you should:

•Send in something that shows the person’s gross income (before taxes and deductions) for this month, such as a pay stub or a letter from the employer. Be sure to send proof for every job listed for each working person.

If no pay has been received for this month, please give us a pay stub from within the last 30 days. For example, if you are applying in September and haven’t yet received pay for September, give us the last pay stub for August (even though this income is not listed on your application).

• If you fill out the self-employment form, you must also send proof of any income and expenses you write about on that form. Proof could be bookkeeping records, contracts, work agreements, payroll records or sales receipts. Tax returns may also be accepted if no other proof is available.

Money from work. Please include a copy of one of these for each person who has money from work:

•copies of the front and back of any health insurance cards, including private insurance, Medicaid from other states, or insurance through an employer

Medical coverage. Please include a copy of this for each person with medical coverage listed on Extra Form E:

•copy of a letter from a doctor or clinic saying this person is pregnant

Pregnancy. Please include a copy of this for each pregnant person:

•American Indian Tribal Enrollment card•certification of Indian blood

• letter showing Indian Health Services program eligibility

For Alaska Natives or American Indians. Please include a copy of one of these:

•check stubs•award letters•written proof

Money from other places. Please include a copy of one of these for each kind of money you listed in part 7:

You do not need to submit proof of income from TANF, Social Security benefits including disability (SSDI) and Supplemental Security Income (SSI), or unemployment benefits received from Oregon.

I have copies of documents that I need for each person who is applying.

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• You read this application, or someone has read it to you, and you understand the questions.

− State, federal, and local officials may check the information that you gave about yourself and anyone who is applying. They do this because it may help decide if you should get benefits.

− We will check Department of Human Services and/or the Oregon Health Authority (DHS or OHA) computer systems and other agency offices, including child support, for information about you and the people applying.

− We may check your U.S. citizen or non-citizen status.

• The information you put on this application is true, complete, and correct as far as you know.

− It is against the law to provide false information. If you do not tell the truth on this application or give information that is not complete, you may be breaking the law and could be fined and face jail time. You may have to pay for any benefits that you received by mistake.

• You have read the Green Booklet and agree to all sections.

• Representatives from DHS or OHA can look at the health records of anyone who is applying. The reason they look is for the purpose of providing health benefits.

• Starting today, you will turn over rights to any health insurance payments to DHS or OHA. For example, if you have an accident or injury, DHS or OHA will have the right to any financial support or payments for medical care from the person who is responsible.

− You must cooperate with DHS or OHA to identify and provide information about anyone who may be responsible for paying for your care.

• You will try to find out about any other benefits for which you (or anyone for whom you are applying) might qualify. This includes cash medical support and health care coverage from absent parents, unless (1) you think the absent parent would cause harm to you or your child, or (2) your child is receiving state Children’s Health Insurance Program benefits.

• If the person receiving benefits dies, be it you or your child, the state may recover the amount of medical benefits received after the age of 55 from the estate of the person who received benefits. This includes monthly payments made by DHS or OHA to managed care plans.

• In cases where the person receiving benefits is in an institution (such as a nursing home) for 6 months prior to death, the state will recover money for all medical benefits provided regardless of age when received.

• The state will not claim this money if the person receiving benefits has children who are under age 21, blind, or permanently and totally disabled.

• If the person receiving benefits has a spouse, the state will wait until the spouse dies before claiming the money.

Important notes and your responsibilities. When you sign your name on this application it means that:

Please be sure to sign this form on the next page.

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Social Security number (SSN) – These federal laws say that anyone applying for medical benefits must provide an SSN: Federal laws – 42 USC 1320b-7(a), 7 USC 2011-2036, 42 CFR 435.910, 42 CFR 435.920, and 42 CFR 457.340(b).When you write your SSN on the application it means that you give permission for DHS or OHA to use it and tell others about it for these reasons:• To help us decide if you qualify for benefits. We will use the

SSNs to make sure the income and assets you gave on the application are correct. We will match that information with other state and federal records, such as Internal Revenue Service, Department of Revenue, Medicaid, child support, Social Security, and unemployment benefits.

• To write reports about the Oregon Health Plan or Healthy Kids. • If the SSN is needed in order to administer the program you

apply for or receive benefits from. • To help us improve the programs by doing quality reviews and

other activities. • To make sure that we have given you the correct amount of

benefits and to recover money if we have overpaid benefits.

See pages 23–25 of the Green Booklet for the full list of your rights and responsibilities.

OHA 7210W (Rev 6/12)

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Sign this online application by typing in your name (first name, middle initial, last name). Be sure to include your phone number.

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Your signature: Phone number:

Next steps.

•Mail your copies of documents listed on page 16 to:

OHP Processing Center PO Box 14520 Salem, OR 97309-5044

•Or, you can fax these copies to 503-373-7493

•A caseworker will call or send you a letter if you need to send any other information.

•We will decide what benefits you are eligible for within 45 days. If you do not get a letter within 45 days after you submit your application, call 1-800-699-9075 (TTY 711).

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Click here to print a copy for your records before you submit.

After you have printed your copy, read the checklist, and filled out any Extra Forms, click here to submit this application.

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18OHA 7210W (Rev 6/12)