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Documents Needed to Enroll in Medicaid, Child Health Plus and Family Health Plus
US CITIZENS:
US Citizenship, Identity and Date of Birth
You can provide ONE of the following documents to prove US Citizenship, Identity and your Date of Birth:
• U.S. passport book/card OR
• Certificate of Naturalization (DHS Forms N-550 or N-570) OR
• Certificate of U.S Citizenship (DHS Forms N-560 or N-561) OR
• NYS Enhanced Driver's License (EDL).
Effective 7/1/10, children who provide a social security number are not required to provide identity or citizenship documentation if eligible for Child Health Plus.
When one of the above documents is not available, ONE document from EACH of the lists below may be used to prove your citizenship and/or identity.
US Citizenship
• US Birth Certificate
• Certificate of Birth issued by Department of State
• Report of Birth Abroad (FS-240)
• US National ID card (Form I-197 or I-179)
• Native American Tribal Document*
• Religious/School Records*
• Military record of service showing U.S. place of birth
• Final adoption decree
• Evidence of qualifying for US citizenship under the Child Citizenship Act of 2000
Identity
• State Driver's license or ID card with photo*
• ID card issued by a federal, state, or local government agency
• US Military card or draft record or US Coast Guard Merchant Mariner Card
• School ID card with a photo (may also show date of birth)
• Certificate of Degree of Indian blood or other Native American/Alaska Native tribal document with photo
• Verified School, Nursery or Daycare records (for children under 16)
• Clinic, Doctor or Hospital records (for children under 16)*
*Documents show date of birth
If you do not have one of the documents that show date of birth (with *), you must also submit one of the following:
• Marriage certificate
• NYS Benefit Identification Card
IF YOU ARE NOT A US CITIZEN:
We need to see ONE of the following documents to prove Immigration Status, Identity and your Date of Birth. The list below contains some of the most common US Citizenship and Immigration Services (USCIS) forms used to show your immigration status.
Immigration Status/Identity
• I-551 Permanent Resident Card (Green Card)*
• I-688B or I-766 Employment Authorization Card*
Immigration Status, but require an additional Identity document
• I-94 Arrival/Departure Record*
• USCIS Form I-797 Notice of Action
• Evidence of Continuous U.S Residence prior to January 1, 1972
* Documents with * next to it also show date of birth
Home Address: This address should be the same address you use on the application. The proof must be dated within 6 months of when you sign the application:
• Lease/letter/rent receipt with your home address from landlord
• Utility bill (gas, electric phone, cable, fuel or water)
• Property tax records or mortgage statement
• Driver's license (if issued within past 6 months)
• Government ID card with address
• Postmarked envelope or post card (cannot use if sent to a P.O Box)
PROOF OF CURRENT INCOME (OR INCOME YOU MIGHT GET IN THE FUTURE LIKE UNEMPLOYMENT BENEFITS OR A LAWSUIT)
You must provide a letter, written statement or copy of check or stubs, from your employer. You do not need to show all of these documents, only the ones that apply to you and the people living with you - one proof for each type of income is required. Provide dated proof of income for the last six weeks, including the employee's name and gross income for the pay period.
Wages and Salary
• Paycheck stubs
• Letter from employer on company letterhead, signed and dated
• Current signed and dated income tax return ass Schedules
• Business/payroll records
Self-Employment
• Current signed and dated income tax return and all schedules
• Records of earnings and expenses/business records
Unemployment Benefits
• Award letter/certificate
• Monthly benefit statement from NYS Department of Labor
• Copy of Direct Payment Card with printout
• Correspondence from the NYS Department of Labor
Private Pensions/Annuities
• Statement from pension/annuity
Social Security
• Award letter/certificate
• Annual benefit statement
• Correspondence from Social Security Administration
Worker's Compensation
• Award letter
• Check stub
Child Support/Alimony
• Letter from person providing support
• Letter from court
• Child support/alimony check stub
Veteran's Benefits
• Award letter
• Benefit check stub
• Correspondence from Veterans Affairs
Military Pay
• Award letter
• Check stub
Income from Rent or Room/Board
• Letter from roomer, boarder, tenant
• Check stub
Interest/Dividends/Royalties
• Recent statement from bank, credit union or financial institution
• Letter from broker
• Letter from agent
• 1099 or tax return (if no other documentation is available)
Support from Other Family Members
• Signed statement or letter from family member
ADDITIONAL INFORMATION NEEDED
Child care cost (care for a disabled person):
If you have to pay for child care (or care of a disabled parent) while you work, provide one of the following:
• Written statement from day care center or other child/adult care provider
• Canceled checks or receipts that show your payments
Proof of health insurance: Provide all that apply:
• Proof of current insurance (Insurance policy, Certificate of Insurance or Insurance Card)
• Health Insurance Termination Letter
• Medicare card
Proof of pregnancy (pregnant women only): Provide one of the following:
• Presumptive Eligibility Screening Worksheet for pregnant women completed by a qualified provider with the expected date of delivery
• Statement from doctor or nurse practitioner with the expected date of delivery
• WIC Medical Referral Form with the expected date of delivery
Medical bills: If you have medical bills in the last three months, provide all the following:
• Proof of income for the months in which the expense was incurred
• Proof of residency/home address for the months in which the expense was incurred
• Medical bills for the last three months, whether or not you paid them
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