APPLICATION FOR HEALTH CARE COVERAGE FOR UNINSURED CHILDREN AND ADULTS

Capital Advantage Insurance Company Commonwealth of Pennsylvania Edward G. Rendell, Governor APPLICATION FOR HEALTH CARE COVERAGE FOR UNINSURED CHILDREN AND ADULTS Application Information The information that you supply on this form will be used to determine eligibility for you and/or your spouse for our Special Care program and your children for the free or low-cost Children s Health Insurance Program (CHIP) or Medical Assistance. Complete the entire application and sign the form. All child applicants (birth up to age 19) will be screened automatically for CHIP and Medical Assistance. Any child applicant who appears to meet Medical Assistance guidelines will be referred for a determination of eligibility. If a child is found to be eligible for CHIP or Medical Assistance, he/she will not be eligible for Special Care and will automatically be enrolled in CHIP or Medical Assistance, as appropriate. Applicants enrolled in health insurance through an employer group, Medical Assistance, CHIP, or Medicare are not eligible for Special Care. Return your complete application, along with your income documents, in the enclosed envelope. We will notify you to request premium payment, if applicable. Mail this application along with your income documentation to: P.O. Box 772612 Harrisburg, PA 17177-2612 CHIP Information To be eligible for CHIP your child must meet the following requirements: Be under 19 years of age. Be a United States citizen, permanent alien, or refugee. Not currently covered by health insurance. Not be eligible for or enrolled in Medical Assistance. If you live in Franklin or Fulton county, CHIP coverage is issued by Capital Advantage Insurance Company. If you live in Adams, Berks, Centre, Columbia, Cumberland, Dauphin, Juniata, Lancaster, Lebanon, Lehigh, Mifflin, Montour, Northampton, Northumberland, Perry, Schuylkill, Snyder, Union, or York counties, CHIP coverage is issued by Keystone Health Plan Central. If you have any questions about CHIP please call 1-800-KIDS-101. (For the hearing impaired 1-800-242-4816) or visit our Web site at www.capbluecross.com/chip. Special Care Information To be eligible for Special Care: Must reside within the Capital BlueCross service area. Must meet income requirements. Cannot be eligible for or enrolled in Medical Assistance, Medicare, or CHIP. Cannot be enrolled in an employer group health plan; or eligible for an employer group health plan where the group is paying 100% of the premium. Special Care hospitalization coverage is issued by Capital BlueCross. Special Care medical-surgical coverage is issued by Capital Advantage Insurance Company. If you are applying for Special Care and you need coverage in the next 30 days or, if you have questions, please call 1-800-962-2242.

Applicant Information Last First Middle Initial For Plan Use Only (eff. date) 1. Street Address City State ZIP Code PA County Email Address Home Phone (with area code) Work Phone (with area code) Best Time to Call Household Information Please list the people who live with you. Start with yourself. Is this person: How is this person related to you? Residency Status 2. Last name, First name, MI* Are you applying for this person? Yes No Sex Male Female Married Single Divorced Separated Widowed Birth date MM/DD/YYYY Social Security Number Is this person a student under age 19? Yes No Child Stepchild Spouse Yourself Self U.S. Citizen Permanent Alien** Refugee** Temporary Alien Undocumented Alien Person 2 Person 3 Person 4 Person 5 Person 6 * If there are additional people who live with you, please use a separate sheet to tell us about them. ** If individual is a permanent legal alien or refugee please attach permanent resident card or certification letter from The Office of Refugee Resettlement.

3. What to Report? Report all income, earnings, and other money everyone in your household receives (do not report wages for a child who is a student and under age 19). Make sure to report your spouse s wages. If you are a student over 19 years of age and living with your parents, only include your income. How to Report Income? On the next page, provide response for each income source. Do this for each person receiving income. If there are multiple sources of income and you need additional space, please provide details on a separate sheet of paper. What To Send as Proof of Income? After you complete the application, make copies of ALL SOURCES of your HOUSEHOLD INCOME. We require proof from each source. Proof includes pay stubs, unemployment notices or check stubs, pension check stubs, alimony and child support award letters, Social Security or Survivor s Benefits award letters or check stubs, veteran s benefit check stubs and/or workers compensation notices. If you are self-employed, send us last year s Federal Tax Return showing your business earnings and deductions with all schedules. All income documents must be dated within the past 60 days (except tax returns). Only one pay stub is required if the stub represents average wages if income varies, send one month s worth of pay stubs. Household Size and Income Instructions New Job? If you don t have enough pay stubs, ask your new employer to type a letter on the company letterhead with your full name, your gross wages, how often you get paid, and your average monthly hours. Your employer must sign and date the letter. Household Members Without Income? If members of your household have no income to report, you must complete the section below for each zero income household member that is age 19 or older. Please attach extra sheets for more than two persons. Note: Attempts to become eligible for Special Care or CHIP through fraud or other misrepresentation may result in the termination of your coverage. There may be penalties for knowingly giving false information. PLEASE ONLY SEND COPIES We cannot return originals. Full of Household Member without Income Person 1 Is person a full time student? Yes No Household Members Without Income (OVER AGE 18) Full of Household Member without Income Person 2 Is person a full time student? Yes No If Yes, please send a copy of your most recent course schedule or a letter from the school registrars office on their letterhead stating you are a full time student. Either document must be signed and dated by a school official. Currently seeking work? Yes No Disabled and waiting for SSI? Yes No If Yes, please send a copy of your most recent course schedule or a letter from the school registrars office on their letterhead stating you are a full time student. Either document must be signed and dated by a school official. Currently seeking work? Yes No Disabled and waiting for SSI? Yes No Who pays this person s living expenses? Is the person who pays this person s expenses the: Parent/Guardian Spouse (describe) For the previous answer, will this person pay the premium Yes No If not, who will pay the premium? Who pays this person s living expenses? Is the person who pays this person s expenses the: Parent/Guardian Spouse (describe) For the previous answer, will this person pay the premium Yes No If not, who will pay the premium?

Income and Expenses Please tell us about the income of any child or adult you have listed on this application. Does anyone have income from: (Please check Yes or No) Yes No Whose income is this? Employment How often is income received? (Weekly, bi-weekly, monthly, etc.) Amount of income received before taxes and deductions Child Care, Adult Care, and Transportation Expenses Some of your expenses can help make you eligible. Please tell us what you pay for child care and adult care, and what you pay for transportation to go to work. Employer s Number of months worked? months Child Care and Adult Care Expenses Is this a contracted or salaried position? If Yes, what is your annual gross amount of pay (before taxes) $ of child or disabled adult Monthly expense amount Employment Employer s Number of months worked? months Is this a contracted or salaried position? If Yes, what is your annual gross amount of pay (before taxes) $ 4. Self Employment (Including baby sitting, room and board, and rental property) Social Security Income for Retirement, Survivors, and Disability Supplemental Security Income (SSI) Transportation Expenses How much does it cost you to get to work each week if you ride with another person or take a bus, subway, or trolley? Pension/Retirement Workers' Compensation If you drive to work, how many miles do you drive each week? Unemployment Benefits (If Yes, date benefits started) Dividends/Interest MM/DD/YYYY If you have a car, how much is your monthly payment? Child Support/Alimony Public Assistance (Specify)

Health Insurance This section must be completed to determine your eligibility for health care coverage. Even if you currently have health insurance, Medical Assistance can sometimes pay bills that other health insurance doesn t cover. Does anyone you are applying for have health insurance? Yes No Has anyone you are applying for had health insurance within the last six months? Yes No Have you, your spouse, or children lost health insurance coverage because either you or your spouse are no longer employed? Yes No If Yes, who lost coverage? If you answered Yes to any of the questions above, please fill in the next section and tell us all you can about the insurance.* If you have or had more than one kind of insurance, please fill in a box for each policy. If more than one person has or had insurance, please fill in a box for each person. Insurance company name Who holds this policy? Who is covered? Policy number When did this insurance start? What is covered? Hospital Care Prescriptions Vision Doctor's Visit Dental Group number/name When did or will this insurance stop? (Leave blank if it is not ending) Insurance company name Who holds this policy? 5. Who is covered? Policy number When did this insurance start? What is covered? Hospital Care Prescriptions Vision Doctor's Visit Dental Group number/name When did or will this insurance stop? (Leave blank if it is not ending) *If you need more space, please attach a separate sheet of paper. Has anyone you are applying for been denied full or partial private health insurance coverage due to a preexisting condition (such as asthma, diabetes, or past injuries)? Yes No If Yes, please list the name(s) of the person(s) denied coverage due to a preexisting condition (this will not affect eligibility for CHIP or Medical Assistance). Who was denied? Who was denied? Who was denied? Who was denied? Medical Assistance can sometimes buy health insurance for you or your child from your employer. Please help us decide if this is possible by completing this section. Can you get health insurance for yourself through your work? Yes No If Yes, would you have to pay for it? Yes No If Yes, what percentage would you have to pay? Can you get health insurance for your child through your work? Yes No If Yes, would you have to pay for it? Yes No If Yes, what percentage would you have to pay? In the last 30 days, did anyone in your family lose a job where they had health insurance? Yes No Do you or any of your family members who are applying for this coverage intend to apply for any other coverage? Yes No If Yes who? Are you converting from other Capital BlueCross coverage or Transferring from another Blue Cross or Blue Shield Plan? Converting Transferring Neither If you are converting or transferring please complete the following information. If not, please skip to the next section. Identification Number: Full of Blue Cross or Blue Shield Plan: What date will your coverage end on:

Stepparent Information Are you, or is anyone who lives with you, a stepparent? Yes No If the answer is No, skip to Section 5. Car Insurance Car insurance will often pay for injuries that occur in an accident. Medicaid and CHIP will pay for only what the car insurance does not cover. 6. Do the stepchildren live with you? Yes No Do you have car insurance? Yes No Stepparent s name Insurance company name Who holds this policy? 7. Stepparent for which child? Stepparent s name Policy number Policy expiration date Stepparent for which child? 8. Special Qualifying Information If someone you are applying for is pregnant or has a disability or a special health care need, a higher income limit can be used when your family applies for Medicaid. Additional services are available for these individuals. Please help us find out if anyone you are applying for is eligible for these additional services. Are you, or anyone who lives with you, currently medically diagnosed as pregnant, or currently being medically treated for pregnancy? Yes No Due date Due date Have you, or anyone who lives with you, been medically diagnosed or treated for a disability, a chronic condition, an ongoing special health care need, or has any medical professional currently prescribed any health-sustaining medications for any medical condition? Yes No If Yes, tell us who, and about their needs below. Did anyone receive SSI in the past? Yes No What is the disability or condition? (optional) What is the disability or condition? (optional) Has this person applied for disability benefits (for example, Social Security Disability, SSI, Workers Compensation, Private Disability Insurance or special assistance with medical bills) because of this condition? Yes No Has this person applied for disability benefits (for example, Social Security Disability, SSI, Workers Compensation, Private Disability Insurance or special assistance with medical bills) because of this condition? Yes No If SSI was stopped, was it because he or she began to get social security? Yes No If SSI was stopped, was it because he or she began to get social security? Yes No

Optional Information (NONE OF THESE ANSWERS WILL EFFECT YOUR APPLICATION FOR HEALTH CARE COVERAGE) Help with child support and health insurance. If you are eligible for Medicaid, you may be able to get help with child support payments and with health insurance for your child if he or she has a parent who does not live with you. Please complete the section below. Your child can still receive health care coverage if you do not complete this section. of absent parent Deceased Absent parent s address 9. Date of birth: Social security number Which child is this parent responsible for? of absent parent Deceased Absent parent s address Date of birth: Social security number Which child is this parent responsible for? Racial and ethnic information is about the people who live with you. Start with yourself. Race (check all that apply) Ethnicity 10. Your name Person 2 Person 3 Person 4 *If there are additional people who live with you, please use a separate sheet to tell us about them. Physician Information African Asian Caucasian African Asian Caucasian African Asian Caucasian African Asian Caucasian Native Alaskan/American Indian Native Hawaiian/American Indian Asian (Indian subcontinent) Native Alaskan/American Indian Native Hawaiian/American Indian Asian (Indian subcontinent) Native Alaskan/American Indian Native Hawaiian/American Indian Asian (Indian subcontinent) Native Alaskan/American Indian Native Hawaiian/American Indian Asian (Indian subcontinent) Hispanic Non-Hispanic Hispanic Non-Hispanic Hispanic Non-Hispanic Hispanic Non-Hispanic If your children are found eligible for CHIP, you will have to select a Primary Care Physician (PCP) for them. Space has been provided below for you to include the name and address of your child(ren) s current physician. If their current physician is in the participating physician network, we will assign the current physician as their PCP. If the current physician is not in the network, you will receive a request by mail to select a different physician for your child(ren) s PCP. Child s name Physician s name Physician s address 11. Help With Unpaid Medical Bills You may be able to get help from Medical Assistance for unpaid medical bills from the last 3 months. Do you have any unpaid medical bills for anyone you are applying for? Yes No

12. Special Care This is to inform you that, as part of our procedure for processing your application for Special Care Coverage, an investigative report to verify the information on this eligibility verification form may be made. Such information may be obtained through personal interviews with employers, family members, business associates, financial sources, friends, neighbors, or other third parties with whom you are acquainted. You have the right to make a written request, within a reasonable period of time, for complete disclosure of additional information concerning the nature and scope of the investigation. I/we verify that the information given on this eligibility verification form is true and correct to the best of my/our knowledge and belief. Any person who knowingly and with intent to defraud any insurance company or other person, files an application for insurance or statement of claim containing any materially false information or conceals for the purpose of misleading, information concerning any fact material thereto, commits a fraudulent insurance act, which is a crime and subjects such person to criminal and civil penalties. I/we understand that if my/our income should change in such a way as to not meet the eligibility requirements set forth for the program, I/we will immediately notify Capital BlueCross and Capital Advantage Insurance Company. CHIP I have read and fully understand this application. The information that I have given is true and correct. I understand that there may be penalties for knowingly giving false information. I understand that if some or all of my children do not qualify for CHIP, they may qualify for Medical Assistance. If this is the case, I will allow CHIP to give my name and the information on this application to the Department of Public Welfare. I understand that I can request an impartial review of an eligibility determination if I do not agree with a CHIP eligibility decision made on this application. I agree to help in the review of the CHIP program. I understand this may include interviews, and a review of my child s health records and application form. By signing my name below, I certify that the persons that I am applying for are U.S. citizens or aliens in lawful immigration status. I know I must sign this in order to be eligible for Medical Assistance or CHIP under law. (An alien who is applying only for Medical Assistance emergency health benefits does not have to sign this certification.) Notification and Authorization Medical Assistance I understand that the information on this form will be kept confidential. I authorize the release of personal, financial, and medical information for the purpose of determining eligibility and for review of the CHIP and Medical Assistance programs. I understand that I must report all changes in my household or financial situation to the County Assistance Office within one week. I understand I will receive a written notice explaining the benefits. I understand that I can request a hearing if I do not agree with a decision made on this application. I understand that my situation is subject to verification from employers, financial sources, and other third parties. I understand that Medical Assistance applicants must provide their Social Security Number. This number may be used to check the information on this application. I understand that I do not have to provide a Social Security Number for anyone who is not applying for Medical Assistance. If I do provide their Social Security Number, it may be used to check information on this application. I understand that I have a right to a certificate of creditable coverage to verify my medical coverage. Federal law limits when health coverage may be denied or limited for a preexisting condition. If I enroll in a group health plan that has a preexisting condition, I can get credit for the time I received Medical Assistance. I understand that if some or all of the individuals applying do not qualify for Medical Assistance, they may be eligible for CHIP or adultbasic. If this is the case, then I will allow the Department of Public Welfare to give my name and information on this application to the Insurance Department or the CHIP contractor or the adultbasic contractor. I understand my rights and responsibilities under CHIP and adultbasic. I certify that all information on this application is true under penalty of perjury. I certify to the best of my knowledge that I understand my rights and responsibilities. By signing my name below, I certify that the persons that I am applying for are U.S. citizens or aliens in lawful immigration status. I know I must sign this in order to be eligible for Medical Assistance or CHIP under law. (An alien who is applying only for Medical Assistance emergency health benefits does not have to sign this certification.) To the best of my/our knowledge and belief, the information provided on this application is true and correct. Signature of applicant or person applying for applicant(s) Date Spouse s Signature Date Note to Special Care applicants: If you are married, your spouse must also sign even if only one of you is applying for coverage. Note to all applicants: If you are married and applying for husband and wife or family coverage, both you and your spouse must sign this application form. If you are unmarried, under age 18 and applying for individual coverage, a parent or guardian must sign. If, in addition to you and your spouse, you are applying for a child on this application, your child will be screened automatically for CHIP and Medical Assistance eligibility. If a child is found eligible for CHIP or Medical Assistance, he/she will not be eligible for Special Care and will be automatically enrolled in CHIP or Medical Assistance, as appropriate. THIS APPLICATION IS VALID ONLY WHEN COMPLETED AND SIGNED BY THE APPLICANT AND HIS/HER SPOUSE. PLEASE REMEMBER TO INCLUDE YOUR INCOME DOCUMENTATION.

Commonwealth of Pennsylvania Edward G. Rendell, Governor Health care benefit programs issued or administered by Capital BlueCross and/or its subsidiaries, Capital Advantage Insurance Company and Keystone Health Plan Central, independent licensees of the Blue Cross and Blue Shield Association, through a contract with the Commonwealth of Pennsylvania. Communications issued by Capital BlueCross in its capacity as administrator of programs and provider relations for all companies. HMO coverage is issued by Keystone Health Plan Central and POS coverage is issued by Capital Advantage Insurance Company.