form-94 - Medicaid Application - 10.2022

Sep 19, 2026

Upload by Skyler

Medicaid Application Form 94 (Revised 10/2022) gathers applicant identity, mailing and residence addresses, contact details, preferred language, and information needed to determine eligibility categories such as pregnant woman, women’s health, children under 19, parent caretaker, Katie Beckett, and related programs. The form also records whether foster care applies, requests Americans with Disabilities Act reasonable modifications and communication assistance, and provides an option to appoint an authorized representative with related accessibility requests. It includes notification preferences for email or texting and collects household members and Medicaid coverage preferences, with guidance on SSN and immigration-status information.

LanguageEnglish

CategoryForms

FormatPDF

Pages6

Reading Time2 min

AccessFree to download

Medicaid Application

Eligibility Categories and Interview Notice

Applicant Information

Preferred Language and Communication Assistance (ADA)

Authorized Representative Section

Notification Preferences (Email/Text) and Household Members

We will consider this application without regard to race, color, sex, age, disability, religion, or national origin. Check block(s) that apply to you: MEDICAID APPLICATION 􀀁 Pregnant Woman 􀀁 Women’s Health FOR COUNTY USE ONLY: Date Received in County Dept. 􀀁 Child under 19 􀀁 Parent Caretaker 􀀁 Katie Beckett 􀀁 Chafee Independence Program Medicaid 􀀁 Planning for Health Babies (P4HB) Were you in foster care on your 18th birthday? Yes No, in which state? PLEASE NOTE: A face-to-face interview is not required for Medicaid applications. Please answer all questions as completely and accurately as possible. If you need help reading or completing this document or need help communicating with us, ask us or call (877) 423-4746. Our services, including interpreters, are free. If you are deaf, hard-ofhearing, deaf-blind or have difficulty speaking, you can call us at the number above by dialing 711 (Georgia Relay). | Your Name: (Please Print) FIRST M.I. Last Maiden (if applicable) | | Today’s Date: | | | --- | --- | --- | --- | | Mailing Address: | City: | State: | Zip Code: | | Residence Address (if different from Mailing Address): | Phone Number(s): | E-mail Address: | | | Electronic Communication: Yes or No (optional)* | What is your Preferred Language?
If an interview is required, will you need an interpreter? Yes No | | | | Americans with Disabilities Act: Request for Reasonable Modification & Communication Assistance (if applicable):
Do you have a disability that will require a Reasonable Modification or Communication Assistance? Yes No (If yes, please describe the Reasonable Modification or Communication Assistance that you are requesting):
Sign Language interpreter ; TTY ; Large Print ; Electronic communication (email) ; Braille ; Video Relay ; Cued Speech Interpreter ;
Oral Interpreter ; Tactile Interpreter ; Telephone call reminder of program deadlines ; Telephonic signature (if applicable) ; Face-to-face interview (home visit) ; Other:
Do you need this Reasonable Modification or Communication Assistance one-time or ongoing ? If possible, briefly explain when and how long you need this modification or assistance? | | | | YOU CAN CHOOSE AN AUTHORIZED REPRESENTATIVE You can give a trusted person or organization permission to talk about this application with us, see your information, and act for you on matters related to this application, including getting information about your application and signing your application on your behalf. This person or organization is called an “authorized representative.” If you ever need to change your authorized representative, contact Division of Family and Children Services (DFCS) at (877) 423-4746. If you are a legally appointed representative for someone on this application, submit proof with the application. | Person Name: (Please Print) FIRST Last | | Organization Name (if applicable): | | | --- | --- | --- | --- | | Address: | City: | State: | Zip Code: | | What is your Preferred Language?
If an interview is required, will you need an interpreter? Yes No | Phone Number(s): | Electronic Communication: Yes or
No (optional)*
E-mail address: | | | Authorized Representative Duties: Sign application on applicant’s behalf ❑ Complete and submit renewal form ❑ Receive copies of notices and other communication ❑
Act on behalf of applicant in all other matters ❑ | | | | | Americans with Disabilities Act: Request for Reasonable Modification & Communication Assistance for Authorized Representatives (if applicable):
Does the Authorized Representative have a disability that will require a Reasonable Modification or Communication Assistance? Yes No (If yes, please describe the Reasonable Modification or Communication Assistance that you are requesting):
Sign Language interpreter ; TTY ; Large Print ; Electronic communication (email) ; Braille ; Video Relay ; Cued Speech Interpreter ; Oral

FAQs

What information is collected in the Medicaid application form?

The form collects your name, addresses, phone and email, preferred language, and whether you fit specific Medicaid eligibility categories. It also asks about foster care history and household members you want covered.

Is a face-to-face interview required to apply for Medicaid?

No. The form states that a face-to-face interview is not required for Medicaid applications.

How can an applicant request accessibility help or accommodations?

You can request Americans with Disabilities Act reasonable modifications and communication assistance (such as sign language interpreter, TTY, large print, braille, or video relay). You must also indicate whether the need is one-time or ongoing and describe timing and duration if applicable.

Sep 19, 2026

Upload by Skyler