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Includes selections for coverage categories such as pregnant women, women’s health, children under 19, parent caretakers, Katie Beckett, Chafee Independence Program, and Planning for Health Babies (P4HB), plus questions about foster care status. 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Yes No, in which state?   \nPLEASE 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-of-hearing,  \nFOR COUNTY USE ONLY: Date Received in County Dept.  \nWe will consider this application without regard to race, color, sex, age, disability, religion, or national origin.  \ndeaf-blind or have difficulty speaking, you can call us at the number above by dialing 711 (Georgia Relay).  \n\n| Your Name: (Please Print) FIRST M.I. Last Maiden (if applicable) |  | Today’s Date: |  |\n| --- | --- | --- | --- |\n| Mailing Address: | City: | State: | Zip Code: |\n| Residence Address (if different from Mailing Address): | Phone Number(s): | E-mail Address: |  |\n| Electronic Communication: Yes  or No  (optional)* | What is your Preferred Language?\u003Cbr>If an interview is required, will you need an interpreter? Yes  No  |  |  |\n| Americans with Disabilities Act: Request for Reasonable Modification & Communication Assistance (if applicable):\u003Cbr>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):\u003Cbr>Sign Language interpreter  ; TTY  ; Large Print  ; Electronic communication (email)  ; Braille  ; Video Relay  ; Cued Speech Interpreter  ;\u003Cbr>Oral Interpreter  ; Tactile Interpreter  ; Telephone call reminder of program deadlines  ; Telephonic signature (if applicable)   ; Face-to-face interview (home visit)   ; Other:  \u003Cbr>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?\u003Cbr>\u003Cbr>|  |  |  |\n\nYOU CAN CHOOSE AN AUTHORIZED REPRESENTATIVE  \nYou 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.  \nThis 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.  \n\n| Person Name: (Please Print) FIRST Last |  | Organization Name (if applicable): |  |\n| --- | --- | --- | --- |\n| Address: | City: | State: | Zip Code: |\n| What is your Preferred Language?\u003Cbr>If an interview is required, will you need an interpreter? Yes   No   | Phone Number(s): | Electronic Communication: Yes  or\u003Cbr>No  (optional)*\u003Cbr>E-mail address: |  |\n| Authorized Representative Duties: Sign application on applicant’s behalf ❑ Complete and submit renewal form ❑ Receive copies of notices and other communication ❑\u003Cbr>Act on behalf of applicant in all other matters ❑ |  |  |  |\n| Americans with Disabilities Act: Request for Reasonable Modification & Communication Assistance for Authorized Representatives (if applicable):\u003Cbr>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):\u003Cbr>Sign Language interpreter  ; TTY  ; Large Print  ; Electronic communication (email)  ; Braille  ; Video Relay  ; Cued Speech Interpreter  ; ","cbCaiiAEtHxwL0L0","https://ap.wps.com/l/cbCaiiAEtHxwL0L0","pdf",804367,"English","# Medicaid Application\n## Coverage Selections\n## Applicant Information\n## Authorized Representative\n## Americans with Disabilities Act (ADA) Communication Assistance\n## Notification Preferences","[{\"question\":\"Do applicants need a face-to-face interview to apply for Medicaid?\",\"answer\":\"No. A face-to-face interview is not required for Medicaid applications.\"},{\"question\":\"Which coverage groups can you select on this application?\",\"answer\":\"You can check boxes for pregnant woman, women’s health, child under 19, parent caretaker, Katie Beckett, Chafee Independence Program Medicaid, and Planning for Health Babies (P4HB).\"},{\"question\":\"How does the form address requests for communication assistance under the Americans with Disabilities Act?\",\"answer\":\"It includes an ADA section where you can indicate whether you need reasonable modification or communication assistance and specify options (such as sign language interpreter, TTY, large print, or video relay), including whether the need is one-time or ongoing.\"}]","Medicaid Application - Pregnancy, Women’s Health, Children, and Authorized Representatives | PDF",1789835190,6]