Oregon Health Plan Application (for OHP PlusMedicaid Program

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Oregon Health Plan Application (for OHP PlusMedicaid Program Powered By Docstoc
					                         Important Information – Before you print
 This document includes:
  n An OHP Application that has not been date stamped, and
  n All the materials included in the OHP Application packet (43 pages)


Why is the date stamp important?
If you are found eligible, the date your coverage will begin is based on the date stamped on your
application. If your application has not been date stamped, the date your coverage begins will be
based on the date we receive your application for processing.


Where do I get a date stamped OHP application?
	 1.	 Go	to	your	local	DHS	office	(call	800-699-9075	or	711	TTY	for	locations),	or
	 2.	 Call	the	OHP	Application	Center,	at	800-359-9517,	or	711	TTY,	or
 3. Complete and submit the online version of the application. The online version of the application
    can be found at:
    https://apps.state.or.us/mbs/


Where can I find a list of available Managed Care Plans?
When you apply for OHP, you may need to choose a Managed Care Plan. Comparison charts show
the Medical and Dental Plans available in your area and a list of things to consider before choosing
a plan. Comparison charts can be found at:
    www.oregon.gov/DHS/healthplan/data_pubs/planlist/main.shtml


Need help filling out your application?
You	can	get	help	filling	out	your	application	by	calling	800-699-9075	or	711	TTY.


Where do I mail my completed OHP application?
Mail your completed application with all required proof to:
    DHS – Oregon Health Plan Branch
    PO	Box	14520
    Salem,	OR	97309-5044




                                                                                           Page 1 of 43
                                                                               OHP 7210PKT (Rev. 10/09)
                                                                                  Recycle Prior Versions
The following forms are included in this document:
 Page #   Form #        Title
   3      OHP 7229      Need	help	filling	out	your	application?

   5      OHP 7210      OHP Application

   9      OHP 7222      Proof Required for OHP (YELLOW sheet)

   11     OHP 7217      Additional Forms Packet (PINK packet) – this packet contains the
                        following forms:
                        OHP	7226 Additional People

                        DHS	415H      Medical Resources

                        OHP 7214      Disability Information

                        OHP 7201      Absent Parent Information

                        OHP	7218      Optional Assistance

                        DHS	859B      Self-Employment	Income

                        OHP 7219      Low or No Income

                        OHP 7227      Additional Income Sources

                        OHP	7228      Additional Resources

   31     OHP	9025      Information about the OHP (GREEN booklet)




                                                                                     Page 2 of 43
                                                                         OHP 7210PKT (Rev. 10/09)
                                                                            Recycle Prior Versions
Need help filling out your application?
You can get help lling out your application by calling 800-699-9075 or TTY 800-735-2900.


Is your application complete?
Before you mail your application, make sure:
    Your application is signed
    You include all required proofs listed on the YELLOW sheet
    You ll out and sign any forms from the PINK packet that apply


Are you age 65 or older, receiving SSI or Medicare?
If you receive SSI, are eligible for Medicare, or are age 65 or older, you might need to ll out a
different application. Call your local Seniors and People with Disabilities (SPD) or Area Agency on
Aging (AAA) of ce, or 800-282-8096 (voice; TTY 800-735-2900) for more information about the
OHP and other health care programs.


                                                                                       OHP 7229 (04/08)




¿Necesita ayuda para llenar su solicitud?
Puede recibir ayuda para llenar su solicitud llamando al 800-699-9075 o TTY (para personas con
problemas de audición) 800-735-2900.


¿Está completa su solicitud?
Antes de enviar su solicitud por correo, asegúrese de que:
    Su solicitud haya sido rmada
    Incluya todos los comprobantes requeridos en la hoja AMARILLA
    Llene y rme todos los formularios del paquete ROSA que correspondan


¿Tiene 65 años de edad o más, recibe SSI o Medicare?
Si recibe SSI, reúne los requisitos para Medicare, o si tiene 65 años de edad o más, puede
necesitar llenar una solicitud diferente. Llame a la o cina local de Personas de la Tercera Edad y
Gente con Discapacidades (Seniors and People with Disabilities: SPD) o a la o cina de la Agencia
sobre el Envejecimiento del Área (Area Agency on Aging: AAA), o al 800-282-8096 (voz; TTY, para
personas con problemas de audición 800-735-2900) para más información sobre el OHP y otros
programas de cuidado de salud.


                                                                               Spanish OHP 7229 (04/08)
Вам необходима помощь в заполнении заявления?
Помощь в заполнении заявления вы можете получить, позвонив по телефону 800-699-9075;
для слабослышащих - 800-735-2900.


Заполнено ли ваше заявление?
Перед тем, как отправить его по почте, удостоверьтесь что:
   вы подписали заявление;
   вы приложили необходимые доказательства, перечисленные на ЖЕЛТОМ бланке;
   вы заполнили и подписали необходимые формы, которые находятся в РОЗОВОМ пакете.


Если ваш возраст 65 лет или старше и вы получаете SSI или Medicare?
Если вы получаете SSI, имеете право на Medicare, ваш возраст 65 лет или старше,
возможно, вам понадобится заполнить другое заявление. Позвоните в местный отдел по
предоставлению услуг пожилым и инвалидам (Seniors and People with Disabilities: SPD) или
в представительство местного агентства для пожилых (Area Agency on Aging: AAA), или по
телефону 800-282-8096 (голос; для слабослышащих - 800-735-2900) для того, чтобы получить
дополнительную информацию об ОНР и других программах здравоохранения.


                                                                           Russian OHP 7229 (04/08)




Quý vị có cần giúp đỡ để điền đơn không?
Quý vị có thể được giúp đỡ điền đơn của quý vị bằng cách gọi điện thọai số 800-699-9075 hoặc
TTY (điện thọai dành cho người điếc) 800-735-2900.


Đơn của quý vị có đầy đủ không?
Trước khi gửi đơn của quý vị đi, hãy chắc chắn:
    Quý vị đã ký tên trên đơn xin
    Quý vị đính kèm tất cả những chứng từ được liệt kê trên bản MÀU VÀNG
    Quý vị điền và ký tên trên tất cả các mẫu thích hợp trên bản MÀU HỒNG


Quý vị được 65 tuổi trở lên và hiện đang nhận SSI hoặc Medicare không?
Nếu quý vị nhận Trợ Cấp Lợi Tức An Sinh Phụ Trội (SSI), hợp lệ nhận Medicare, hoặc từ 65 trở
lên, quý vị có thể cần điền một đơn khác. Hãy gọi điện thọai cho Sở Cao Niên và Người Khuyết Tật
(Seniors and People with Disabilities: SPD) hoặc văn phòng Cơ Quan Khu Vực Phụ Trách về Cao
Niên (Area Agency on Aging: AAA), hoặc số 800-282-8096 [âm thọai; TTY (điện thọai dành cho
người điếc) 800-735-2900] để biết thêm tin tức về chương trình OHP và những chương trình săn
sóc y tế khác.


                                                                        Vietnamese OHP 7229 (04/08)
          Date of Request        Date Received by Branch   Program        Branch         Case Number                        Worker ID


                                              Case to 8)
     Print your completed OHP application (pages 5Name                                                                      Route to:


                                               Prime Number
     Save a blank copy of this packet to your computer                                      SSN                             App Status


                                                           Office use only
          Clear all pages of the OHP application packet



    Oregon Health Plan Application (OHP 7210)
    If you need help filling this out, call 800-699-9075 or TTY 800-735-2900

1    Name (Last, First, M.I.)                                                               Maiden or other names used


     Phone number                                                    Message number
      (            )                                                 (               )
     Home address – ZIP required, see GREEN booklet               City                       State      ZIP


     Mailing address (if different)                               City                       State      ZIP


2    List yourself and everyone living with you. To list more than four people, use the OHP 7226 form, found in the
     PINK packet.
    Social Security numbers (SSNs)* – If you don’t have an SSN, write in “none.”
    Ethnicity/Racial Heritage – Write in all the codes that apply. Title VI of the Civil Rights Act of 1964 allows us to
       ask for this information. You can choose not to give this information. It will not affect your eligibility for benefits.

          Ethnicity                            Racial Heritage
          H – Hispanic or Latino               A – Asian                                   P – Native Hawaiian or Other Pacific
          N – Not Hispanic or Latino           B – Black or African American                   Islander
                                               I – American Indian/Alaska Native           W – White
                                                                             Applying    * Social       * U.S citizen?       Ethnicity
                Name                  Relation           Date and              for       Security        Proof required,
                                                                                                                                  Racial
           (Last, First, M.I.)         to you Sex   City/State of birth      benefits    Number        see YELLOW sheet         Heritage
a.                                            nM                             n Yes                     n Yes
                                       Self   nF                             n No                      n No, non-citizen#
                                                                                                       ______________
b.                                            nM                             n Yes                     n Yes
                                              nF                             n No                      n No, non-citizen#
                                                                                                       ______________
c.                                            nM                             n Yes                     n Yes
                                              nF                             n No                      n No, non-citizen#
                                                                                                       ______________
d.                                            nM                             n Yes                     n Yes
                                              nF                             n No                      n No, non-citizen#
                                                                                                       ______________

* Only required for people who are applying for benefits.
                                                                                                                    OHP 7210 (Rev 10/09)
                      We might not need the following information about everyone
                     who lives with you. Page 2 of the GREEN booklet explains what
                information is needed for roommates and others living in your household.

3    Do you and the people you are applying for live in Oregon?                                        Yes       No

4    In the last six months, including this month, has anyone had public or private health             Yes       No
     insurance? For children under 19, we only need information about this month and last
     month. Do not count any OHP coverage. If yes, fill out the DHS 415H form, found in
     the PINK packet.

5    Does anyone have health insurance through an employer or absent parent or other                   Yes       No
     source? If yes, fill out the DHS 415H form, found in the PINK packet.

6    Is anyone disabled or does anyone have a condition that could be life-threatening                 Yes       No
     or disabling if not treated? Age 19 and over, fill out the OHP 7214 form, found in the
     PINK packet.
     Under age 19 list name:
7    Do any children under age 19, including unborn children, have parent(s) who do not                Yes       No
     live with you? If yes, fill out the OHP 7201 form, found in the PINK packet.

8    Is anyone an American Indian/Alaska Native or eligible for benefits through an Indian             Yes       No
     Health Services program? Proof is required, see YELLOW sheet.
     If yes, who?
9    Is anyone pregnant? Proof is required, see YELLOW sheet.                                          Yes       No
     If yes, who?                                                  Due date:
10   If anyone is pregnant, does the father of the unborn child live with you?                         Yes       No
     If yes, his name is?
11   Is anyone age ≥ 16 or older attending school? Proof is required for some students,                Yes       No
     see YELLOW sheet.
     If yes, who?
12   Does your partner or spouse make you afraid by threatening, yelling, or physically                Yes       No
     hurting you or your children? See page 13 of the GREEN booklet for more
     information.

13   Does anyone qualify for Medicare? Medicare is medical coverage from Social                        Yes       No
     Security for people who are disabled or age 65 and older.
     If yes, who?
14   Do you want to name someone to represent you or for us to release information to? If              Yes       No
     yes, fill out the OHP 7218 form, found in the PINK packet.

15   Do you need future materials in a language other than English or in a different way?              Yes       No
     For example, Braille? If yes, fill out the OHP 7218 form, found in the PINK packet.

16   Has anyone had self-employment income this month or last month? If yes, fill out the              Yes       No
     DHS 859B form, found in the PINK packet.

17   You must choose an OHP Medical and Dental Plan. See page 10 of the GREEN
     booklet for special instructions. Do not write in OHP or DMAP.
     Medical – 1st choice                                         2nd choice
     Dental – 1st choice                                          2nd choice
                                                                                          OHP 7210 (Rev 10/09) – Page 2
        If you need help filling out this application, call 800-699-9075 or TTY 800-735-2900

18   Has anyone had income from any source this month or last month? If yes, fill out the                  Yes       No
     chart below. Proof is required, see YELLOW sheet. Examples of income include a
     job, child support, Social Security, unemployment or Workers’ Compensation, rental
     property, Veterans’ affairs, or a trust fund.
     ■ If you had low or no income, fill out the OHP 7219 form, found in the PINK packet.
     ■ For income from self-employment, write “self-employed” in income source #1 and
        fill out the DHS 859B form, found in the PINK packet.
     ■ Use the OHP 7227 form, found in the PINK packet to list more income sources.
                                     Income source #1                  Income source #2         Income source #3
     Paid to (first name)
     Income from (name)
     How often paid
     Dates paid
     Amount received. Give
     the gross amount –          This month $                      This month $             This month $
     before deductions. Write
     in how much you have
     and expect to receive.      Last month $                      Last month $             Last month $


19   Does anyone have any of the resources listed below? If yes, complete the following                    Yes       No
     charts. Use the OHP 7228 form, found in the PINK packet to list more resources.
     If you are only applying for children under 19, mark no and write “child” in the chart
     below.
                                                  Bank name and location            Balance/value      Belongs to?
     Checking account
     Savings account
     Other resources – such as cash,      List the type:
     stocks, bonds, or certificates of
     deposit (CD)

     Important: Having a vehicle or other assets will not affect your eligibility for OHP. We use this information
       to determine if you are eligible for other DHS Medical Programs.

                                                             Type                   Equity value*      Belongs to?
     Vehicle #1                           Year:            Make:
     Other assets – such as property,
     land or buildings other than the
     home you live in.
     * For example, your car/asset is worth $1,000 and you owe $400. The equity value is $600 ($1,000 - $400 = $600).

20   By signing this application, I understand and agree to the following:
     a. I am giving true and complete information and I understand giving false or incomplete information may
        delay or stop my benefits. It also can cause an overpayment of benefits that I must repay.
     b. Social Security numbers (SSNs) – The federal laws listed below, require anyone applying for
        medical benefits to give the Department of Human Services (DHS) their SSN. This requirement does
        not apply to anyone who is not applying for benefits. 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).
                                                                                              OHP 7210 (Rev 10/09) – Page 3
   c. I allow DHS to use the SSNs I have given to:
      ■ Help decide if I am eligible for benefits. SSNs will be used to verify income, other assets, and to
         match with other state and federal records such as IRS, Medicaid, child support, Social Security
         and unemployment benefits.
      ■ Prepare reports requested by funding sources for the program I apply for or receive benefits from.
   d. I understand DHS may use or disclose the SSNs I have given:
      ■ If they are needed to operate the program I apply for or receive benefits from.
      ■ To conduct quality assessment and improvement activities.
      ■ To verify the correct level of benefits and recover overpaid benefits.
      ■ To make sure nobody gets benefits in more than one household.
   e. I have read, understand and agree to the following sections of the GREEN booklet (OHP 9025):
      ■ OHP Premiums – page 9
      ■ DHS and OHP Managed Care: Disclosure or Exchange of Specific Protected Health Information for
         Treatment Purposes Without Authorization – page 12
      ■ Non-Discrimination Statement – page 15
      ■ Oregon Health Plan Rights and Responsibilities – page 16
   f.   I allow DHS representatives to review the health care records of myself and anyone I apply for.
   g. I allow DHS to share the health care records of myself and anyone I apply for with other DHS
      agencies, and DHS contractors and their providers.
   h. I will give proof of the statements I have made, and allow DHS to contact other people and agencies
      to get proof I do not have.
   i. I agree to cooperate with DHS if my case gets chosen for a review.
   j.   I agree to turn over my rights to any health insurance payments, starting today. If I have an accident
        or injury, I “assign” any rights to support and payment of medical care to DHS. I will cooperate in
        identifying and providing information to assist DHS in pursuing anyone who may be liable to pay for
        my care, unless I have good cause. This is so DHS can get repaid for paying my health care bills.
        This agreement is for myself and anyone I apply for.
   k. I understand that I have a responsibility to pursue any benefits that I or anyone I apply for might be
      eligible for. This includes cash medical support and health care coverage from absent parents, unless:
      ■ I think the absent parent would cause harm to me or my child, or
      ■ My child is receiving State Children’s Health Insurance Program benefits.
   l.   The State’s Right to Recover Medical Benefits – DHS may claim money from my estate for DHS
        medical benefits I receive after I reach age 55. This includes monthly capitation payments DHS made
        to Managed Care Plans regardless of the amount of medical care actually provided. Some cash
        benefits can be recovered regardless of age. DHS may also claim money from my estate for all DHS
        medical benefits I received, regardless of my age, if I am institutionalized for the last 6 months of my
        life. DHS will not claim this money if I have children who are under age 21, or blind, or permanently
        and totally disabled. DHS will wait until my spouse dies before submitting a claim.

    By signing this form, I affirm under penalty of perjury I have given true, complete information.

Print legal name of applicant                                           Signature                             Date



Print legal name of spouse, other parent/adult in the household         Signature                             Date




                                                                                         OHP 7210 (Rev 10/09) – Page 4
                                                   YELLOW sheet


        Proof Required for OHP – (OHP 7222)
2   U.S. Citizenship and           Important note: If you are not a U.S. citizen you may still qualify. The
    Identity                       following proof is only required if you are a U.S. citizen.

    We do not need proof of        We need proof of U.S. citizenship and identity for most people applying for
    U.S. citizenship or identity   medical benefits. Examples of proof are listed below. See pages 4-8 of the
    to begin your medical          GREEN booklet for a complete list.
    coverage. Do not wait
                                   If you have already given us your proof, we do not need to see it again.
    until you have proof to
    turn in your application.      We must look at your original documents or copies certified by the issuing
    Turn in your application as    agency. Take or mail your documents to any DHS field office (call
    soon as possible.              800-699-9075 or TTY 800-735-2900 for locations). If you mail in your
                                   documents, we will mail them back to you.

                                   Examples of Proof – U.S. Citizenship and identity
                                   n U.S. Passport
                                   n Certificate of Naturalization
                                   n Certificate of U.S. Citizenship

                                   Examples of Proof – U.S. Citizenship
                                   n U.S. birth certificate
                                   n Hospital record
                                   n Life, health or other insurance records
                                   n American Indian Tribal Enrollment or Certification of Indian Blood

                                   Examples of Proof – Identity
                                   n State issued driver’s license
                                   n Oregon Fish and Wildlife license
                                   n A parent or guardian’s signature on the application is considered proof of
                                     identity for children under age 16 when no other identity is available.

8   American Indian/Alaska         If you or anyone in your household is an American Indian/Alaska Native, you
    Native                         must send a copy of your proof of heritage, membership with a federally
                                   recognized tribe, or a letter showing Indian Health Services (IHS) program
                                   eligibility. See page 15 of the GREEN booklet for more information.

9   Pregnancy information          If you or anyone in your household is pregnant, you must send proof. Proof
                                   must be from a doctor, Public Health Department, clinic, or any type of
                                   pregnancy resource center or clinic.

                                                                                              OHP 7222 (Rev 10/09)
11   Education   Proof is not required for students age ≥ 16 or over unless they are attending
                 college, technical or vocational school. Send the following proof for students
                 age ≥ 16 or over who are attending college, technical or vocational school:
                 n A copy of the first page of your Student Aid Report (SAR). This page
                   shows your Expected Family Contribution (EFC), and
                 n A note that lists:
                   t Student’s name and name of school
                   t Number of credit hours this term, and
                   t Whether the student is an undergraduate or a graduate

18   Income      You must send proof of the income you listed. Proof can be a copy of your
                 pay stubs, or a letter from your employer or the person who paid you. A letter
                 from your employer must include a contact name and phone number.




                                                                           OHP 7222 (Rev 10/09)
                                                         PINK packet



                      Additional Forms Packet
This packet includes all of the forms you might need to fill out when applying for Oregon Health Plan (OHP)
or Healthy Kids coverage. The forms in this packet are listed below and include the reasons you would fill
them out.


             Use with
             question:      Form number and name

                  2         OHP 7226 – Additional People (04/08)

                  4         DHS 415H – Medical Resources (02/08)

                  6         OHP 7214 – Disability Information (04/08)

                  7         OHP 7201 – Absent Parent Information (04/08)

             14 and 15      OHP 7218 – Optional Assistance (10/09)

                 16         DHS 859B – Self-Employment Income (10/09)

                 18         OHP 7219 – Low or No Income (04/08)

                 18         OHP 7227 – Additional Income Sources (10/09)

                 19         OHP 7228 – Additional Resources (04/08)




                                                                                      OHP 7217 (Rev 10/09)
                                                                                  Agency Use Only
          Additional People                           Program       Branch        Case Number                    Worker ID
            (OHP 7226)
                                                    Print your completed "Additional People" form (pages 13 to 14)
                                                     Case Name                                       Route to:
         Complete this form if you need
         to list more people in your                  Prime Number                SSN                            App Status
         household (question 2).


     Remember, when listing everyone living with you:
     Social Security numbers (SSNs)* – If you don’t have an SSN, write in “none.”
     Ethnicity/Racial Heritage – Write in all the codes that apply. Title VI of the Civil Rights Act of 1964 allows
        us to ask for this information. You can choose not to give this information. It will not affect your eligibility
        for benefits.
       Ethnicity                              Racial Heritage
       H – Hispanic or Latino                 A – Asian                                  P – Native Hawaiian or Other Pacific
       N – Not Hispanic or Latino             B – Black or African American                  Islander
                                              I – American Indian/Alaska Native          W – White

                                                                          Applying      * Social    * U.S citizen?      Ethnicity
              Name                 Relation              Date and           for         Security     Proof required,
                                                                                                                             Racial
         (Last, First, M.I.)        to you Sex      city/state of birth   benefits       Number     see YELLOW sheet        Heritage
e.                                           M                            Yes                     Yes
                                     S       F                            No                      No, non-citizen#
                                                                                                   ______________

f.                                           M                            Yes                     Yes
                                             F                            No                      No, non-citizen#
                                                                                                   ______________

g.                                           M                            Yes                     Yes
                                             F                            No                      No, non-citizen#
                                                                                                   ______________

h.                                           M                            Yes                     Yes
                                             F                            No                      No, non-citizen#
                                                                                                   ______________

i.                                           M                            Yes                     Yes
                                             F                            No                      No, non-citizen#
                                                                                                   ______________

j.                                           M                            Yes                     Yes
                                             F                            No                      No, non-citizen#
                                                                                                   ______________

* Only required for people who are applying for benefits.



                                 You can list more people on the back of this page

     Print legal name of applicant                                                Signature                              Date

     Print legal name of spouse, other parent/adult in the household              Signature                              Date


                                                                                                                OHP 7226 (04/08)
                                                                Applying   * Social    * U.S citizen?      Ethnicity
           Name             Relation           Date and           for      Security     Proof required,
                                                                                                                Racial
      (Last, First, M.I.)    to you Sex   city/state of birth   benefits    Number     see YELLOW sheet        Heritage
k.                                   M                          Yes                  Yes
                             S       F                          No                   No, non-citizen#
                                                                                      ______________

l.                                   M                          Yes                  Yes
                                     F                          No                   No, non-citizen#
                                                                                      ______________

m.                                   M                          Yes                  Yes
                                     F                          No                   No, non-citizen#
                                                                                      ______________

n.                                   M                          Yes                  Yes
                                     F                          No                   No, non-citizen#
                                                                                      ______________

o.                                   M                          Yes                  Yes
                                     F                          No                   No, non-citizen#
                                                                                      ______________

p.                                   M                          Yes                  Yes
                                     F                          No                   No, non-citizen#
                                                                                      ______________

* Only required for people who are applying for benefits.




                                                                                                   OHP 7226 (04/08)
                                                               Program     Branch      Case Number            Worker ID

                                          DHS 415H            Print your completed "Medical Resources" form (pages 15 to 16)
                                                               Case Name


                                              Medical Resources
Return the completed form and copies of insurance cards (front and back) to the Department of
                Human Services (DHS). DHS will Fax to HIG at (503) 373-0358
                         For each Insurance Policy, complete a section.
         If you have Insurance available through your employer, but are not yet enrolled,
                          contact your local DHS office before enrolling.
                                           List of People Covered by the Policies.
                                  Name                                                  Name
People




                                           Complete below for the Medical policy.
                                                Policy Holder Information
           Name:                                            SSN:                               DOB:
                                             Insurance Company Information
                                  Name                                                 Address
Medical




                                  Phone                                             City, State, Zip
           (    )
                      Group/Health Record Number                                 Policy/I.D. Number

           Date Insurance available:                        Date Insurance no longer available:
                                                   Employer Information
                                  Name                                City, State               Phone Number
                                                                                           (    )

                                          Complete below for the Pharmacy policy.
                                                Policy Holder Information
           Name:                                            SSN:                               DOB:
Pharmacy




                                             Insurance Company Information
                                  Name                                                 Address


                                  Phone                                             City, State, Zip
           (    )
                      Group/Health Record Number                                 Policy/I.D. Number

           Date Insurance available:                         Date Insurance no longer available:
                          For additional Insurance Policies, complete a section on page 2.
                                                        Page 1                                               DHS 0415H (2/08)
                                                         Complete below for the Dental policy.
                                                             Policy Holder Information
                        Name:                                            SSN:                               DOB:
                                                          Insurance Company Information
 Dental


                                               Name                                                 Address


                                               Phone                                             City, State, Zip
                        (    )
                                   Group/Health Record Number                               Policy/I.D. Number

                        Date Insurance available:                         Date Insurance no longer available:
                                                         Complete below for the Vision policy.
                                                             Policy Holder Information
                        Name:                                            SSN:                               DOB:
                                                          Insurance Company Information
 Vision




                                               Name                                                 Address


                                               Phone                                             City, State, Zip
                        (    )
                                   Group/Health Record Number                               Policy/I.D. Number

                        Date Insurance available:                         Date Insurance no longer available:
                                                 Complete below for the Long Term Care (LTC) policy.
 Long Term Care (LTC)




                                                              Policy Holder Information
                        Name:                                             SSN:                       DOB:
                                                          Insurance Company Information
                                               Name                                           Address


                                               Phone                                             City, State, Zip
                        (    )
                                   Group/Health Record Number                               Policy/I.D. Number

                        Date Insurance available:                         Date Insurance no longer available:

 Comments: Good cause for not pursuing health insurance asset:                               safety concerns
   Insurance not available locally   other
The person(s) listed above are required to have a Social Security Number (SSN), under 42 USC 1396b-7(a) and (b), 7
USC 2011-2036, 42 CFR 435.910-920, 42 CFR 457.340(b) and OAR 461-120-0210. The number must be made part
of your case record. DHS will use your SSN to help decide if you are eligible for benefits. Your SSN will be used
to verify your income, other assets, and to match with other state and federal records such as IRS, Medicaid, child
support, Social Security and Unemployment benefits. DHS may use your SSN to prepare aggregate information or
reports requested by funding sources for the program you apply for or receive benefits from. DHS may use or disclose
your SSN if it is needed to operate the program you apply for or receive benefits from; to conduct quality assessment
and improvement activities; to verify the correct amount of payments and recover overpaid benefits; and to make sure
nobody gets benefits in more than one household.
                                                         Page 2                                             DHS 0415H (2/08)
  Disability Information                                                      Agency Use Only
                                                  Program      Branch         Case Number                     Worker ID
       (OHP 7214)
                                                  Case Name                                        Route to:
                                              Print your completed "Disability Information" form (pages 17 to 18)
     Complete this form if you
     checked yes in question 6. If
     any part does not apply to you,              Prime Number                SSN                             App Status
     write N/A.


Part A – List anyone who has been diagnosed with End Stage Renal Disease (ESRD) or received routine
           dialysis treatment, or has received a kidney transplant within the last 36 months.

           Name: ________________________________________________________________________

Part B – Complete the following chart for anyone who is age 19 or older who has a disability.

 1   Name

 2   Describe the disability (see
     examples on the back)




 3   Is this disability expected       Yes
     to last or has it lasted 12
                                       No
     straight months?
 4   Have you applied for              Yes     Applied Month/Year: _______   Approved Month/Year: ________
     disability benefits through                 Denied Month/Year: _______    Appealed Month/Year: ________
     the Social Security
     Administration (SSA)              No
     for this disability?
 5   If your claim was denied:
     a   Has your condition
         worsened since your
         denial? Tell us when it
         got worse and describe
         how.

     b   Do you have a new
         medical condition since
         your denial? Tell us about
         your new condition and
         when it started?


Print legal name of applicant                                                 Signature                               Date

Print legal name of spouse, other parent/adult in the household               Signature                               Date


                                                                                                              OHP 7214 (04/08)
Examples of disabilities
 Loss of both hands or both feet
 Loss of one hand and one foot
 Legal blindness
 Mental retardation with an IQ of 59 or less
 Cancer that has spread to other parts of the body
 Kidney disorder with long term dialysis or kidney transplant in the last 12 months


Examples of health issues that are not considered disabilities
 Pregnancy
 Simple fracture of the arm or leg
 Influenza
 Back strain




                                                                                       OHP 7214 (04/08)
          Absent Parent                                                           Agency Use Only
                                                     Program         Branch       Case Number                          Worker ID
           Information
           (OHP 7201)                                                                                 Route 19
                                                Print your completed "Absent Parent Information" form (pagesto: to 20)
                                                    Case Name


      Complete this form if you                      Prime Number                 SSN                                  App Status
      checked yes in question 7.

                                              Absent Parent #1                                   Absent Parent #2
 1    Name – Last, First, MI
      and last known:
      Address
      City, State, Zip

 2    Date of birth

 3    Social Security
      number – if known
 4    Relation to you

 5    Date of separation

 6    This parent’s children
      shown in question 2 of
      your application
 7    Visits                   This month, this parent has or will visit about:   This month, this parent has or will visit about:
                               ____ hours per week                                ____ hours per week
                               ____ times per week                                ____ times per week

 8    If this is an absent      Yes, by      Marriage                            Yes, by      Marriage
                                              Court order                                       Court order
      father, has paternity
                                              Birth Certificate                                  Birth Certificate
      been legally                            Other _____________________                       Other _____________________
      established?
                                No                                                No
                                Don’t know                                        Don’t know

 9    Can your child get        Yes – If yes, complete the DHS 415H, found        Yes – If yes, complete the DHS 415H, found
                                 in the PINK packet.                                in the PINK packet.
      health insurance
      through this parent?      No                                                No
                                Don’t know                                        Don’t know

 10   Do you think this         Yes (explain below)                               Yes (explain below)
      parent might cause        No                                                No
      harm to you or the
      child if we try to
      establish paternity
      and pursue health
      care coverage? If yes,
      explain.


                         You can list more absent parents on the back of this page

Print legal name of applicant                                                     Signature                                   Date

Print legal name of spouse, other parent/adult in the household                   Signature                                   Date


                                                                                                                      OHP 7201 (04/08)
                                             Absent Parent #3                                   Absent Parent #4
1    Name – Last, First, MI
     and last known:
     Address
     City, State, Zip

2    Date of birth

3    Social Security
     number – if known
4    Relation to you

5    Date of separation

6    This parent’s children
     shown in question 2 of
     your application
7    Visits                   This month, this parent has or will visit about:   This month, this parent has or will visit about:
                              ____ hours per week                                ____ hours per week
                              ____ times per week                                ____ times per week

8    If this is an absent      Yes, by      Marriage                            Yes, by      Marriage
                                             Court order                                       Court order
     father, has paternity
                                             Birth Certificate                                  Birth Certificate
     been legally                            Other _____________________                       Other _____________________
     established?
                               No                                                No
                               Don’t know                                        Don’t know

9    Can your child get        Yes – If yes, complete the DHS 415H, found        Yes – If yes, complete the DHS 415H, found
                                in the PINK packet.                                in the PINK packet.
     health insurance
     through this parent?      No                                                No
                               Don’t know                                        Don’t know

10   Do you think this         Yes (explain below)                               Yes (explain below)
     parent might cause        No                                                No
     harm to you or the
     child if we try to
     establish paternity
     and pursue health
     care coverage? If yes,
     explain.




                                                                                                                     OHP 7201 (04/08)
  Optional Assistance                                                 Agency Use Only
                                              Program     Branch      Case Number                  Worker ID
      (OHP 7218)
                                          Print your completed "Optional Assistance" form (pages 21 to 22)
                                              Case Name                                     Route to:
 Complete part A or B of this form
 if you checked yes in question 14.
 Complete part C or D of this form            Prime Number            SSN                          App Status
 if you checked yes in question 15.

Part A – Authorized Representatives: The Department of Human Services (DHS) can only discuss your
       case with you or someone you name. The person you name can be anyone who is not listed on your
       application. To name someone to represent you, complete the following. This authorization will be in
       effect until your health care coverage ends unless you notify us. This authorization only applies to
       interactions between the Authorized Representative and DHS.
       Important information about Authorized Representatives:
       n This person can give or get information about your case.
       n This person can sign your application if you are not able to. You are still responsible for any
          information given on your application.
       n Your worker will send letters to this person’s name at your address.


       Name (Last, First, M.I.) _____________________________________________________________

       Relationship to you _______________________________                  (      )
                                                                      Phone _________________________


Part B – Authorization to Release Information: DHS can only discuss your case with you or someone
       you name. The person you name can be anyone who is not listed on your application. To name
       someone for DHS to release information to, complete the following. This authorization will be in
       effect until your health care coverage ends unless you notify us. This authorization only applies to
       interactions between the person you name and DHS.
       Important information about authorization to release information:
       n This person can give or get information about your case.
       n This person cannot sign your application.
       n This person’s name will not be listed on letters sent to you by your worker.


       Name (Last, First, M.I.) _____________________________________________________________

       Relationship to you _______________________________                  (      )
                                                                      Phone _________________________


Part C – Alternate Formats: We can provide written materials in different formats. If you want written
       materials in a different format, check the box that applies:
       n Large print –   large print materials are printed in this size
       n Audiotape – information is recorded on an audiocassette tape
       n Braille – information is printed in Braille
       n	 Computer	disk	–	information	is	saved	as	“plain	text”	on	a	3.5-inch	floppy	disk
       n Spoken – information is read by a DHS employee in person or over the telephone

                                 Don’t forget to sign the back of this form.
                                                                                               OHP 7218 (Rev 10/09)
Part D – Other languages: We provide some written materials in other languages. If you want written
        materials in a language other than English, check the box that applies:
        n Bosnian                n Korean                  n Romanian              n Spanish
        n Cambodian              n Laotian                 n Russian               n Vietnamese
        n Cantonese              n Mandarin                n Somali                n Other ___________


        If you need an interpreter, check the box that applies:
        n Bosnian                n Korean                  n Romanian              n Spanish
        n Cambodian              n Laotian                 n Russian               n Vietnamese
        n Cantonese              n Mandarin                n Somali                n Other ___________




Print legal name of applicant                                          Signature                           Date

Print legal name of spouse, other parent/adult in the household        Signature                           Date


                                                                                               OHP 7218 (Rev 10/09)
                                                                                     Program:                Branch:                  Case number:    Wkr. ID:
                                       DHS 859B
    Oregon Department of Human Services
            Dep                                                                      Case name: completed "Self-Employment Income" form (page 23)
                                                                                       Print your
    Children, Adults and Families

                                                       Self-Employment Income
Business name:                                                                       Business address:

Type of business:                                                                    Business phone number:                            Is this business incorporated?
                                                                                                                                           Yes       No
                                                                                                                   Expected     Last
                                                                                                                  this month   month
Gross income (Total of all sales and receipts, before costs.) ................................................... $          $
Business costs
 A. Wages paid to employees
    Employee name                                                                                                                      $               $
    Employee name                                                                                                                      $               $
 B. Business property (Do not count costs related to your personal home. You can
     include prorated costs for a separate office within your home.)
            1.   Rent ...................................................................................................              $               $
            2.   Taxes and assessments ....................................................................                            $               $
            3.   Utilities (water, lights, heat) ..................................................................................    $               $
            4.   Interest on mortgage .........................................................................                        $               $
            5.   Insurance premiums .........................................................................                          $               $
 C. Equipment
         1. Services, repair and rental of business equipment that is owned,
            leased or rented (including motor vehicles) ............................................. $                                                $
         2. Taxes and assessments .................................................................... $                                               $
 D. Professional fees, legal fees, license and permits (bookkeeper, attorney, etc.) $                                                                  $
 E. Operating supplies (stationery, postage, cleaning supplies, meals etc... )                                                         $               $
 F. Repairs to business equipment or motor vehicles                                                                                    $               $
 G. Advertising (newspaper, business cards, signs, flyers, etc...)                                                                      $               $
 H. Interest paid on business loans                                                                                                    $               $
 I. Telephone for business                                                                                                             $               $
 J. Travel ($.20 per mile. Do not count commuting costs.)                                                                              $               $
 K. Materials purchased for resale (Such as cosmetic products. For newspaper
     carriers include the cost of newspapers, bags and rubber bands.)                                                                  $               $
 L. Materials used to make a product                                                                                                   $               $
 M. Other costs not listed above (describe)                                                                                            $               $


Provide proof of your self-employment income and costs. Proof could be bookkeeping
records, copies of contracts, copies of work agreements and sales receipts. Tell your worker
if you don't have all the proof.



Signature                                                                                                            Date
                                                                                                                        DHS 0859B (10/09) Page 1, Recycle prior versions
                                                                      Agency Use Only
     Low or No Income                         Program     Branch       Case Number                  Worker ID
        (OHP 7219)
                                             Case Name                                Route to:
                                           Print your completed "Low or No Income" form (page 25)
 Complete this form if you have low
 or no income to report for any of            Prime Number             SSN                          App Status
 the months listed in question 18.

How are you meeting your basic living needs? Basic living needs are things like food, shelter, clothing.

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________
____________________________________________________________________

____________________________________________________________________

____________________________________________________________________

____________________________________________________________________




Print legal name of applicant                                         Signature                             Date

Print legal name of spouse, other parent/adult in the household       Signature                             Date


                                                                                                OHP 7219 (Rev 04/08)
          Additional                                                        Agency Use Only
                                                 Program     Branch         Case Number                  Worker ID
      Income Sources
         (OHP 7227)                            Print your completed "Additional Income Sources" form (pages 27-28)
                                                 Case Name                                          Route to:

   Complete this form if you need
   to list more income sources                   Prime Number               SSN                          App Status
   (question 18).

Remember:
n Proof is required, see YELLOW sheet.
n Examples of income include a job, child support, Social Security, unemployment or Workers’ Compensation,
  rental property, Veterans’ affairs, or a trust fund.
n If you had low or no income, fill out the OHP 7219, found in the PINK packet.
n For income from self-employment, fill out the DHS 859B form, found in the PINK packet.


                                    Income source #4             Income source #5             Income source #6
    Paid to (first name)
    Income from (name)
    How often paid
    Dates paid
    Amount received. Give
    the gross amount –          This month $                 This month $                 This month $
    before deductions. Write
    in how much you have
    and expect to receive.      Last month $                 Last month $                 Last month $




                                    Income source #7             Income source #8             Income source #9
    Paid to (first name)
    Income from (name)
    How often paid
    Dates paid
    Amount received. Give
    the gross amount –          This month $                 This month $                 This month $
    before deductions. Write
    in how much you have
    and expect to receive.      Last month $                 Last month $                 Last month $




                      You can list more income sources on the back of this page

Print legal name of applicant                                               Signature                           Date

Print legal name of spouse, other parent/adult in the household             Signature                           Date


                                                                                                    OHP 7227 (Rev 10/09)
                              Income source #10      Income source #11      Income source #12
Paid to (first name)
Income from (name)
How often paid
Dates paid
Amount received. Give
the gross amount –         This month $           This month $           This month $
before deductions. Write
in how much you have
and expect to receive.     Last month $           Last month $           Last month $




                              Income source #13      Income source #14      Income source #15
Paid to (first name)
Income from (name)
How often paid
Dates paid
Amount received. Give
the gross amount –         This month $           This month $           This month $
before deductions. Write
in how much you have
and expect to receive.     Last month $           Last month $           Last month $




                                                                                   OHP 7227 (Rev 10/09)
                                                                        Agency Use Only
  Additional Resources                             Program   Branch      Case Number                    Worker ID
       (OHP 7228)
                                                 Case Name                                       Route 29-30)
                                               Print your completed "Additional Resources" form (pagesto:
   Complete this form if you
   need to list more resources                     Prime Number          SSN                            App Status
   (question 19).


List additional resources below. To list additional vehicles and other assets, turn this page over.

                                             Bank name and location            Balance/Value          Belongs to?
                      Checking
Account #2            Savings
                      Checking
Account #3            Savings
                      Checking
Account #4            Savings
                      Checking
Account #5            Savings
                      Checking
Account #6            Savings
                      Checking
Account #7            Savings
                      Checking
Account #8            Savings
                      Checking
Account #9            Savings
                      Checking
Account #10           Savings
                      Checking
Account #11           Savings
Other resources – such            List the type:
as cash, stocks, bonds, or
certificates of deposit (CD)       List the type:


                                  List the type:


                                  List the type:


                                  List the type:


                                  List the type:




                         You can list more resources on the back of this page

Print legal name of applicant                                           Signature                               Date

Print legal name of spouse, other parent/adult in the household         Signature                               Date


                                                                                                        OHP 7228 (04/08)
Remember:

 Equity value is the amount your car/asset is worth minus the amount you owe. For example, your car is
  worth $1,000, but you owe $400. The equity value of your car is $600 ($1,000 - $400 = $600).

                                                    Type                  Equity value       Belongs to?

Vehicle #2                      Year:       Make:


Vehicle #3                      Year:       Make:


Vehicle #4                      Year:       Make:


Vehicle #5                      Year:       Make:
Other assets – such as
property, land or buildings
other than the home you
live in.




                                                                                               OHP 7228 (04/08)
GREEN booklet


                                Print the "Information about the Oregon Health Plan" booklet (pages 31-46)




         OHP 9025 (Rev 10/09)
                            Table of Contents                                                  Eligibility requirements...........................................................13
                                                                                                    Special rules for victims of domestic violence ...................13
What is DHS? ..........................................................................1
                                                                                                    Special rules for higher education students.......................14
What is OHP?..........................................................................1             Special rules for people with disabilities ............................14
What is Healthy Kids? .............................................................2
                                                                                                    Natives...............................................................................15
Are you eligible? ......................................................................2
                                                                                               Non-discrimination statement ................................................15
When will you hear from us? ...................................................2
                                                                                               OHP rights and responsibilities .............................................16
Why do we want to know about everyone who
lives with you? .........................................................................2     Other health resources ..........................................................18
                                                                                                    Medicare............................................................................18
Using a mailing address ..........................................................3
                                                                                                                                                                  .......................19
Why we need Social Security numbers ...................................4
                                                                                                                                                              ............................19
U.S. citizenship and identity requirements ..............................4                                                                                            ...................20
   How can you prove your U.S. citizenship                                                                                                                                 ..............20
   and identity? ........................................................................5
                                                                                               Domestic violence resources.................................................21
   Born in Oregon? ..................................................................5
   Don’t have the necessary documents? ...............................5
   Proof of U.S. citizenship and identity...................................5
   Proof of U.S. citizenship ......................................................6
   Proof of identity....................................................................7
                                                      .....................................7
                                                     ......................................8

OHP premiums ........................................................................9

Managed care........................................................................10
   DHS and OHP managed care: disclosure or

   for treatment purposes without authorization ....................12

Information about the Oregon Health Plan                                                   i   ii                                     Information about the Oregon Health Plan
What is DHS?                                                        What is Healthy Kids?
The Department of Human Services (DHS) is Oregon’s                  Healthy Kids is a state health care program for children under
statewide health and human services agency. When you                age 19. Depending on your income, your family may qualify for
apply for medical assistance, you may have contact with the         one of three Healthy Kids programs:
following divisions of DHS:                                           OHP
    Children, Adults and Families (CAF) Division – CAF                Premium assistance, where the state helps you pay for
    determines eligibility for programs that provide health care,     your employer-sponsored insurance.
                                                                      Private insurance product, where you can purchase
   incomes. CAF also ensures that health care is provided for         affordable health care coverage through the state. This
   children in foster care and adoptive placements.                   program begins January 1, 2010.
   Division of Medical Assistance Programs (DMAP) –
                                                                    Use the OHP application to apply for all Healthy Kids
   DMAP runs the Medicaid part of the Oregon Health Plan
                                                                    programs.
   (OHP). This means DMAP contracts with health care
   providers to provide health care to people covered by OHP.
   Seniors and People with Disabilities (SPD) Division –            Are you eligible?
   SPD determines eligibility for programs that provide health      There are many ways that you may be eligible. We will use
   care to people who have low income and are disabled, or          your completed application to see if you are eligible for any
   blind, or over 65 years of age.                                  DHS Medical Program.
                                                                    Oregon has other health insurance programs that may be
What is OHP?                                                        available to you. See the “Other Health Resources” on page
The Oregon Health Plan (OHP) is a state program of health           18 for more information.
care for people with low incomes. This health care includes
services for medical care, dental care, mental health and           When will you hear from us?
substance abuse treatment.                                          DHS has 45 days from the date of your request to see if you
                                                                    qualify. If you are eligible, we will send you a letter telling you

   Pay for health care services that you received before you        If you have not heard from us within this time, you may call the
   were found eligible.                                             Statewide Medical Call Center at 800-699-9075 or TTY
   Require you to pay a monthly premium for your OHP                800-735-2900. Be ready to give your name and date of birth.
   coverage.
   Require you to pay a copayment for certain services you          Why do we want to know about everyone who lives
   receive.                                                         with you?

                                                                    who lives with you. However, we may not need income and
                                                                    other information about everyone in your household.


Information about the Oregon Health Plan                        1   2                           Information about the Oregon Health Plan
If you are 19 or older, we want you to answer questions 3-20
                                                                   Why we need Social Security numbers
for you and the following people if they live with you:
    Your spouse                                                    The federal laws listed below require anyone applying for
    Your child or unborn child’s parent
                                                                   (SSN). This requirement does not apply to anyone who is not
    Your child                                                                         Federal laws (42 USC 1320b-7(a), 7
                                                                   USC 2011-2036, 42 CFR 435.910, 42 CFR 435.920 and 42
apply separately.                                                  CFR 457.340(b)
There are some exceptions to this if you are under 19 and          We will use the SSNs you give us to:
married or are under 19 and homeless. Call the Statewide
Medical Call Center at 800-699-9075 or TTY 800-735-2900 for            used to verify income, other assets, and to match with other
instructions.                                                          state and federal records such as IRS, Medicaid, child

Using a mailing address                                                Prepare aggregate information or reports requested by
                                                                       funding sources for the program you apply for or receive
Once you are found eligible for OHP, you will receive a DMAP
Medical Care ID and coverage letter by mail. The coverage
                                                                   We may use or disclose the SSNs you give to us:
managed care enrollment information for everyone in your             If they are needed to operate the program you apply for or
household who gets a Medical Care ID.
It is important that we have your correct address. If we               To conduct quality assessment and improvement activities.
don’t have a way to reach you by mail, you could lose your
coverage.
You may want or need to use a mailing address if you:
                                                                       household.
  Get your mail at a place other than your home address,
  Have safety concerns including domestic violence – this          U.S. citizenship and identity requirements
  can also be your “contact” address (see page 13 for more
  information), or
                                                                   show proof of U.S. citizenship and proof of identity.
  Are homeless.
                                                                   This requirement does not apply to people who are:
                                                                      Not U.S. citizens (current requirements still apply).
we still must have a ZIP code for your home address.
                                                                      Receiving Medicare or Supplemental Security Income (SSI)
If you are homeless, write “homeless” for your home address           or Social Security Disability Insurance (SSDI).
and give the zip code for the place you mainly stay.
All material will be mailed to your mailing address.
                                                                       provide the children’s proof of citizenship and identity).

                                                                       Assistance to Needy Families – TANF).
Information about the Oregon Health Plan                       3   4                           Information about the Oregon Health Plan
How can you prove your U.S. citizenship and identity?               Proof of U.S. citizenship
The documents listed on the next pages can be used to prove         The following documents only prove your U.S. citizenship. You
U.S. citizenship and identity.                                      must also provide one of the documents listed under “Proof of
                                                                    identity.” This is not a complete list of documents. Some of the
by the issuing agency. We cannot accept photocopies. This           documents listed must meet certain requirements or contain
means that you must:

   800-699-9075 or TTY 800-735-2900 for locations), or                                                      Institutional admission
                                                                                                            papers
                                                                        by the Department of State          Medical (clinic, doctor or
                                                                        Report of Birth Abroad of a         hospital) records
You are only required to prove your U.S. citizenship and
                                                                        U.S. Citizen                        Northern Mariana ID Card

Born in Oregon?                                                         Abroad                              be used in very rare
If you were born in Oregon after 1920, we may be able to                U.S. Citizen ID card                circumstances
                                                                        American Indian Tribal              One of the following
                                                                                                            documents that was
to give us proof of identity.                                           of Indian Blood                     created at least 5 years
                                                                        American Indian Card                before applying for medical
Don’t have the necessary documents?                                     issued by the Department
If you do not have the documents you need, call your local              of Homeland Security with             Seneca Indian tribal
                                                                                                              census record
   For information about where to get the documents,                    “KIC”                                 Bureau of Indian Affairs
   For other ways to prove your citizenship and identity, and           Final adoption decree                 tribal census records of
   To explain why you can’t get the documents.                          Evidence of civil service             the Navajo Indians
Pages 7 and 8 list information about how to order birth                 employment by the U.S.                U.S. State Vital
                                                                        government before June
                                                                        1976
                                                                                                              registration
even if you don’t have all of the documents you need.                   service showing a U.S.                An amended U.S. public
                                                                        place of birth                        birth record that is
Proof of U.S. citizenship and identity
                                                                        Hospital record                       amended more than 5
The following documents prove both U.S. citizenship and
                                                                        Life, health or other                 years after the person’s
identity. If you have one of these documents, we do not need
                                                                        insurance records                     birth, or
anything else from you.
                                                                        Federal or state census               A statement signed by
   U.S. Passport
                                                                        records showing U.S.                  the physician or midwife
                                                                        citizenship                           who was in attendance
                                                                                                              at the time of birth
Information about the Oregon Health Plan                        5   6                            Information about the Oregon Health Plan
Proof of identity
The following documents only prove identity. You must also
provide one of the documents listed under “Proof of U.S.              were born in (phone numbers are listed below). The Centers
citizenship.” This is not a complete list of documents. Some          for Disease Control and Prevention’s Web site lists information
of the documents listed must meet certain requirements or
                                                                          www.cdc.gov/nchs/w2w.htm

                                                                      State          Phone #           State           Phone #
   State-issued driver’s              Oregon Fish and Wildlife
                                                                      Alabama        334-206-5418                      402-471-2871
   license                            license
                                                                                     907-465-3391      Nevada          775-684-4280
   ID card issued by the              U.S. Coast Guard
                                                                      Arizona        602-364-1300      New
   federal, state, or local           Merchant Mariner card                                                            603-271-4654
                                                                                     501-661-2336      Hampshire
   government with the same           Military dependent’s ID                        916-445-2684      New Jersey      866-649-8729
   information included on a          card                            California
   driver’s license                                                                  8am - noon        New Mexico      866-534-0051
                                      A parent or guardian’s          Colorado       303-692-2200
                                      signature on the                                                                 212-788-4520
                                                                      Connecticut    860-509-7897      City
   or other U.S. American             application is considered       Delaware       302-744-4549
                                      proof of identity for                                                            518-474-3075
                                                                      Dist. of                         State
   document                           children under age 16                          202-671-5000
                                                                      Columbia                         North
   U.S. military card or draft        when no other identity is                                                        919-733-3000
                                                                      Florida        904-359-6900      Carolina
   record                             available.
                                                                      Georgia        404-679-4702                    701-328-2360
   A school ID card with the                                                                           Ohio          614-466-2531
                                                                      Hawaii         808-586-4533
   person’s picture                                                                                                  405-271-4040
                                                                      Idaho          208-334-5988
                                                                      Illinois       217-782-6553      Oregon        971-673-1190
The Oregon Department of Motor Vehicles (DMV) issues                  Indiana        317-233-2700      Pennsylvania 724-656-3100
photo IDs to people of any age. There is a cost and you will be       Iowa           515-281-4944      Rhode Island 401-222-2811
required to show proof of age, identity and address. For more         Kansas         785-296-1400      South
                                                                                                                     803-898-3630
information:                                                                         502-564-4212      Carolina
    Go to their Web site www.oregon.gov/ODOT/DMV/                     Louisiana      504-219-4500                    605-773-4961
    driverid/, or                                                     Maine          207-287-3181      Tennessee     615-741-1763
    Call one of the following general information numbers:            Maryland       410-764-3038      Texas         512-458-7111
      Salem 503-945-5000                                              Massachu-                        Utah          801-538-6105
                                                                                     617-740-2600      Vermont       802-863-7275
      Portland Metro Area 503-299-9999                                setts
      Bend 541-388-6322                                               Michigan       517-335-8666      Virginia      804-662-6200
      Medford 541-776-6025                                            Minnesota      651-201-5970      Washington 360-236-4300
      Roseburg 541-440-3395                                           Mississippi    601-576-7981      West Virginia 304-558-2931
      Eugene 541-686-7855                                             Missouri       573-751-6387      Wisconsin     608-266-1371
      TTY 503-945-5001                                                Montana        888-877-1946      Wyoming       307-777-7591

Information about the Oregon Health Plan                          7   8                        Information about the Oregon Health Plan
OHP premiums                                                          You will receive a notice when it is time to reapply. When

for health care coverage. This monthly payment is called a            premiums and give you a deadline by which to pay them. If
premium.                                                              you do not pay your past-due premiums by the deadline,
                                                                      you will not be able to enroll in the program again until:
The amount of your premium is based on your gross income
                                                                         The program is open to new clients, and
and family size. The premium amount stays the same until you
reapply.                                                                   You have paid all your billed premiums.
If you are required to pay a premium, a bill will be mailed to        Any clients in the household (children, for example) who are
you each month. You must pay your premium every month,                not required to pay premiums may still reapply. If they are
even if you didn’t see your health care provider. Your premium
will begin the date your coverage begins.                             others in the household do not renew their coverage.

OHP does not charge premiums to clients who are:
                                                                      Managed care
  Pregnant,
                                                                      When you apply for the OHP, you may need to choose a type
  Under age 19,
                                                                      of Managed Care, either an OHP Managed Care Plan and/or
                                                                      Primary Care Manager (PCM) (see “Exceptions” on the next
   through an Indian Health Services program (see page 15             page).
   for requirements),
                                                                      With your application you may receive one of the following:
   Eligible for Temporary Assistance to Needy Families
   (TANF),                                                               An OHP Comparison Chart (OHP 9031) – this shows the
                                                                         OHP Medical and Dental Plans you can choose from in
   Receiving SSI,
                                                                         your area.
   Age 65 or older,
                                                                         An OHP Notice – this shows any OHP Managed Care
   Blind or disabled and receiving income at or below the SSI            Plans that are not available in your area at this time.
   standard,
                                                                         PCM List – If you receive a PCM list, that means there
   Blind or disabled and receiving department paid long term             are no OHP Medical Plans available to you and you must
   care services,                                                        choose a PCM. Your PCM will provide the same types of
   Eligible for the Citizen/Alien Waived Emergent Medical                care that you would get through an OHP Medical Plan. Your
   (CAWEM) program.                                                      PCM will be your Primary Care Provider.
You will not lose coverage during your current enrollment             Write the name of the OHP
period just because you have a past-due premium. However,             Medical Plan or PCM and
when your enrollment period is ending and you reapply, you            OHP Dental Plan you choose
will need to pay all billed premiums before you can qualify for       in question 17.
another six months of coverage.
                                                                      If you do not choose an OHP
                                                                      Managed Care Plan and/or
                                                                      PCM, your application may be
                                                                      delayed or denied.
Information about the Oregon Health Plan                          9   10                         Information about the Oregon Health Plan
                                                                    DHS and OHP managed care: disclosure or exchange

comparison chart or PCM list. You will remain in your current       purposes without authorization
OHP Managed Care Plan and/or PCM unless you write new               Oregon law (ORS 192.518 to 192.526) allows DHS and OHP
names in question 17.                                               Managed Care Plans to share the following protected health
                                                                    information, without your authorization, with an OHP Managed
Exceptions
                                                                    Care Plan for the purpose of treatment activities when the
Below are reasons you will not be enrolled in an OHP                OHP Managed Care Plan is providing behavioral or physical
Managed Care Plan or with a PCM. If any of these apply to           health services to you:
you, follow the instructions listed for your exception.
                                                                        Your name and Medicaid recipient number
1) There are no OHP Managed Care Plans and/or PCMs                      The name of your hospital provider or attending physician
   available in your area write “none available.”
                                                                        Your performing provider’s Medicaid number
                                                                        Your diagnosis
   “AI/AN.” See page 15 for more information and instructions.          Along with the following information about services
                                                                        provided to you:
3) You are already seeing a provider who is not part of an                Dates of service
   available OHP Medical Plan and you:
                                                                          The quantity of units of service provided
     Have surgery scheduled (you will need to choose an
     OHP Medical Plan after the surgery), or                              Procedure and revenue codes
     Are in the last three months of pregnancy and not                    Information about medication prescription and monitoring
     currently enrolled in an OHP Medical Plan (you will need       Information about DHS privacy practices and your privacy
     to choose an OHP Medical Plan after the baby is born).         rights can be found in the DHS Notice of Privacy Practices. To
   Send a note with your application explaining this to us.         get a copy of the DHS Notice of Privacy Practices:
4) You are seeing a provider who is not part of an available           Call 800-699-9075 or TTY 800-735-2900, or
   OHP Dental Plan and you have a dental surgery scheduled.
                                                                         TTY 800-735-2900 for locations), or
   Send a note with your application explaining this to us. You
   will need to choose an OHP Dental Plan after the surgery.             Go to: http://dhsforms.hr.state.or.us/forms/Served/
                                                                         DE2090.pdf.
5) You have been diagnosed with End Stage Renal Disease
   (ESRD) or receive routine dialysis treatment, or you have

   If any of these are true about you or anyone you are

   application. If this person is age 19 or over, complete Part
   A of the Disability Information (OHP 7214) form in the
                               PINK


Information about the Oregon Health Plan                       11   12                        Information about the Oregon Health Plan
Eligibility requirements                                              Special rules for higher education students
                                                                      If you are a full-time higher education student (not including
family, gross income, and resources:                                  Adult Basic Education [ABE], English as a Second Language
   Gross income is the amount before deductions. Income               [ESL], General Education Development [GED] or high school
                                                                      equivalency programs), you may be eligible if you have:
                                                                          An Expected Family Contribution (EFC) of less than $4,618
   compensation, and unemployment.                                        for the 2009/2010 school year or are eligible for a Pell
   Resources                                                              Grant, and
                                                                          Not been covered by commercial,
                                                                          major medical health insurance,
   car do not count as resources.                                         or an HMO in the last six months
You must send proof of the income you listed. Proof can be a              (other than OHP coverage).
copy of your pay stubs, or a letter from your employer or the         If you meet these requirements, send
person who paid you. A letter from your employer must include
a contact name and phone number.                                      Student Aid Report (SAR) with your
                                                                      completed OHP application.
Special rules for victims of domestic violence
                                                                      Your SAR will show your EFC. To
                                                                      receive an SAR, you must apply for
yelling, or physically hurting you or your children, you may be
a victim of domestic violence.                                        for Federal Student Aid (FAFSA).

12 on your application. See page 21 for more information              Special rules for people with disabilities
about domestic violence.                                              People with certain disabilities may qualify for a higher level of
Special rules apply to victims of domestic violence. If you have      medical coverage.
questions, call the Statewide Medical Call Center at
800-699-9075 or TTY 800-735-2900. As a victim of domestic             question 6. If the person with the disability is 19 or older, you
violence you:                                                         must also complete Part B of the Disability Information (OHP
                                                                                                                     PINK
   more information), and
   May refuse to help us establish paternity and pursue health
   care coverage from absent parents if there are safety
   concerns for you or your children.
To get information on safe ways to pursue child support and


(listed under Department of Justice) in the “State” section of

Information about the Oregon Health Plan                         13   14                         Information about the Oregon Health Plan
Special rules for American Indians/Alaska Natives                       OHP rights and responsibilities
                                                                        The following are your rights and responsibilities under the
   A member of a federally recognized Indian tribe, band or             OHP. Please read them carefully to be sure you understand
   group, or

                                                                        You have a right to:
   Claims Settlement Act, 43 U.S.C. 1601, or
                                                                             Get help from us to get child support from absent parents.
   Services program.                                                         Refuse to help us establish paternity and pursue health

                                                                             absent parent would cause harm to you or your child.
Natives:                                                                     Refuse to let us release information you give unless we
  Are not required to pay premiums or copayments, and                        must release it to operate OHP.
  Can choose to be enrolled in an OHP Medical or Dental
  Plan or receive health care services through an Indian
  Health Services program or a federally recognized tribal

   through an Indian Health Services program or federally
   recognized tribal clinic, write “AI/AN” in question 17.                   have 45 days from the date of the notice to do this. You
                                                                             must use the Administrative Hearing Request form (DHS

Native, you must send a copy of one of the following proofs
with your completed application:
   Heritage,                                                            You have a responsibility to:
   Membership with a federally recognized tribe, or                       Help us establish paternity and pursue health care
   A letter showing Indian Health Services (IHS) program
   eligibility.                                                              parent would cause harm to you or your child.


Non-discrimination statement                                                   Changes of address or name
DHS will not discriminate against anyone.                                      Changes of other health care coverage (for example,
                                                                               if health insurance becomes available through an
This means DHS will help all who qualify.                                      employer)
DHS will not deny help to anyone based on age, race, color,                    Pregnancy
national origin, sex, religion, political beliefs or disability.               Newborns
                                                                             Tell health care providers if you have other health insurance
because of any of these reasons.


Information about the Oregon Health Plan                           15   16                         Information about the Oregon Health Plan
   Complain to the managed care plan you have selected and/         Other health resources
   or request a hearing through DMAP if you have problems           Each of the programs listed in this section have different
   getting health care.                                             eligibility requirements. For more information, or to apply for
                                                                    any of these programs, call the toll-free number or go to the
   help for, may qualify. For example: unemployment                 Web site address listed.
   compensation, Social Security, railroad retirement,
                                                                    Medicare                                       800-MEDICARE
                                                                                                                  or 800-633-4227
                                                                                                                 TTY 877-486-2048
                                                                                                                www.medicare.gov
   child or unborn child who has an absent parent, unless:          Who is eligible for Medicare?
                                                                    You may be eligible for Medicare if you:
      your child, or                                                  Are disabled, or
      Your child is receiving State Children’s Health Insurance
                                                                      Are over age 65, or
      You are pregnant, and you only want state medical
      coverage for yourself.
                                                                    Cost to you
                                                                    There are premiums for some parts of the program.
      Helping to locate your child or unborn child’s other
      parent.
      Legally naming the child or unborn child’s father             Medicare offers its members hospital and medical insurance.
      (establishing paternity).                                     Medicare does not cover long-term care or prescriptions and
      Getting an order for health care coverage.                    usually does not pay for all of the medical care needed by
      Getting an order for cash to help with your child’s medical   its members. Medicare members may be eligible for other
      expenses.                                                     programs listed in this section.
   “Support” means money you get for you or your children,
                                                                    (QMB) helps low-income people pay the cost of Medicare. To
   help you pay for your child’s medical expenses.                  apply for this program, call your local Seniors and People with
   When you get DHS medical coverage for your child, you            Disabilities Division (SPD) or Area Agency on Aging (AAA)

   support anyone in your family gets from another person.

   your child gets.
   This means that while you are getting DHS medical

   payments received for you to help pay for your child’s
   medical expenses.
Information about the Oregon Health Plan                      17    18                         Information about the Oregon Health Plan
Family Health Insurance                 888-564-9669
Assistance Program (FHIAP)         TTY 800-735-2900           Partnerships (OPHP)                        TTY 800-735-2900
                         www.oregon.gov/OPHP/FHIAP                                                   www.oregon.gov/OPHP
                                                              Who is eligible for OPHP services?
Call FHIAP or visit their Web site for current eligibility    All Oregon small businesses and individuals needing
requirements. FHIAP may not have openings for new             assistance obtaining health insurance.
members when you call. However, FHIAP sends applications      Cost to you
                                                              Free
your name on the FHIAP Reservation List.

Cost to you                                                   OPHP provides assistance, education, and agent referrals to
As a FHIAP member you will pay a percentage of your
insurance premium costs and any copayments or deductibles     insurance choices.
that your health insurance plan requires.
                                                              Oregon Department of Veterans’                   800-692-9666
                                                              Affairs (ODVA)                          In Salem 503-373-2000
                                                                                                           TTY 800-735-2900
FHIAP will help members pay for health insurance plans
                                                                                                     www.oregon.gov/ODVA

Oregon Medical Insurance                      800-848-7280    Veterans of the U.S. Armed Forces, their spouse, widow, or
Pool (OMIP)                               TTY 800-735-2900    child.
                                 www.oregon.gov/DCBS/OMIP
                                                              Cost to you
                                                              Free consultation. Some veterans’ affairs medical services
Anyone who has been turned down for health insurance          require a copayment.
because of a pre-existing medical condition.

Cost to you
Costs vary by age and location.                                    Medical services/nursing care
                                                                   Vocational training
                                                                   College tuition assistance
OMIP allows you to purchase insurance from private                 Widow’s pension
companies who are part of the program. OMIP is not a low-          Wartime veteran’s pension
cost health insurance program. FHIAP can help pay the costs        Property tax exemption
for this program.
                                                                   Free copies of military records and discharge papers

                                                              Department of Veterans’ Affairs (VA) and other veterans
                                                              programs.
Information about the Oregon Health Plan                 19   20                         Information about the Oregon Health Plan
Domestic violence resources
Domestic violence affects the entire family. We want you and
your family to be safe. No one deserves to be abused.
If you are a victim of domestic violence, you can get help in
one of the following ways (men can also call these numbers):

   local crisis provider, or
   You can call the Portland Women’s Crisis Line at:
   888-235-5333
   800-735-2900 TTY, or
   503-235-5333 in Portland, or
   You can call the National Domestic Violence Hotline at:
   800-799-SAFE
   800-787-3224 TTY

Warning signs of domestic violence
The following is a list of some of the warning signs of an
abusive relationship. You may be in an abusive relationship if
your current or past partner or spouse:
   Puts you down,




   Keeps you from seeing your friends or family,
   Shoves, grabs, slaps, punches, pinches, strangles, or



No one deserves to be abused. You have a right to be safe
from harm. If you are a victim of domestic violence, you
are not alone. Call one of the numbers shown above for

and information.




Information about the Oregon Health Plan                     21