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Application for Health Coverage & Help Paying Costs. Form Approved. OMB No. 0938-1191. You may qualify for a free or low-cost program even if you earn as much as $94,000 a year (for a family of 4). Who can use this application? Apply faster online. What you may need to apply. Why do we ask for this.
Step 1. Fill out the application. Read the questions carefully and give accurate information. Sign and date the application. Step 2. Turn in the application. You will need to tear off pages 1 -3 and keep it for yourself. Mail, fax, or bring in pages 4-8 of this application to your local Division of family & Children Services (DFCS) office.
• Use this application to apply for anyone in your family. • Apply even if you or your child already has health coverage. You could be eligible for lower-cost or free coverage. • If you’re single, you may be able to use a short form. Visit HealthCare.gov. • Families that include immigrants can apply. childYou can apply for your
Application for Benefits. YOU MUST HAND DELIVER, FAX or MAIL THE COMPLETED APPLICATION TO YOUR LOCAL COUNTY OFFICE. or call 1-877-423-4746. If you are deaf or hard of hearing, ple. se call GA Relay at 71. What Services Do We Offer at the Division of Family and Children Services (DFCS)? DFCS offers the following services: Food Assistance.
For info on applying for Medicaid, please review the attached documents. Medicaid Application - English (PDF, 456.05 KB) Medicaid Application - Spanish (PDF, 949.13 KB) Medicaid Application - Attachment A (PDF, 163.25 KB) Medicaid Application - Attachment B (PDF, 139.29 KB)
• Families that include immigrants can apply. You can apply for your child even if you aren’t eligible for coverage. Applying won’t affect your immigration status or chances of becoming a permanent resident or citizen. • If someone is helping you fill out this application, you may need to complete Attachment C.
DBHDD: Provider Recruitment and Application for Developmental Disabilities Services List below the Waiver Services that you are applying to provide and the number of individuals to be served in each Service.