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| Home > Members & Applicants > Document Checklist |
I. PROOF OF IDENTITY - DATE OF BIRTH and RESIDENCE:
You must show ONE of the documents listed in both
categories to see if you are eligible for health insurance. Photocopies are acceptable.
Identity/Date of Birth
Residency/Home Address
II. PROOF OF CURRENT INCOME:
You must provide a letter, written statement, or copy of check or stubs,
from the employer, person or agency providing the income. Submit all that apply. Provide the most recent
proof of income before taxes. The proof must be dated, include the employees name and show gross income for
the pay period.
Wages and Salary
Self-Employment
Unemployment Benefits
Private Pensions/Annuites
Social Security
Child Support/Alimony
Workers Compenstation
Verteran's Benefits
Military Pay
Interest/Dividends/Royalties
Income From Rent or Room/Board
Support From Other Family Members
III. DEPENDENT CARE COSTS
- Written statement from day care center or other child/adult care provider
- Canceled checks or receipts
IV. PROOF OF HEALTH INSURANCE
- Insurance policy
- Termination letter
- Certificate of insurance
- Medicare cared
- Insurance card
V. IMMIGRATION STATUS
- INS form I-551 (Green Card)
- INS form I-94
- Official Hospital/doctor birth records
- INS form I-220B
- INS form I-210 letter
- INS form I-181
- Other INS documentation, or correspondence to or from the INS
VI. FOR MEDICAID, CHILD HEALTH PLUS A and FAMILY HEALTH PLUS ONLY
CITIZENSHIP
- U.S. Birth Certificate
- U.S. Baptismal record, recorded within 3 months of birth
- U.S. Passport
- Naturalization certificate
Resources
VII. PREGNANT WOMEN ONLY
Proof of Pregnancy
VIII. MEDICAID/CHILD HEALTH PLUS A ONLY
For determination of Eligibility for medical expenses from the past 3 months
- Proof of income for the month(s) in which the expense was incurred
- Proof of residency/home address for the month(s) in which the expense was incurred
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