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Connecticut Department of Social Services Medical Assistance Program www.ctdssmap.com TO: RE: Provider Bulletin 2012-06 February 2012 All Providers Presumptive Eligibility Certification and Guarantee

How to fill out presumptive eligibility certification and

How to fill out presumptive eligibility certification:

1. Obtain the presumptive eligibility certification form from the appropriate healthcare agency or organization.
2. Fill out the personal information section accurately, including your full name, date of birth, address, and contact information.
3. Provide details about your current income, employment status, and any other relevant financial information requested on the form.
4. Include information about your household size and composition, including the number of dependents or family members.
5. If applicable, provide any documentation or proof of eligibility criteria specified by the healthcare agency, such as income verification or proof of residency.
6. Review the form for any errors or missing information before submitting it.
7. Sign and date the form, affirming the accuracy of the information provided.
8. Submit the completed presumptive eligibility certification form to the designated healthcare agency or organization.

Who needs presumptive eligibility certification:

1. Individuals who do not currently have health insurance coverage and are seeking temporary coverage.
2. Individuals with limited income who might be eligible for certain government healthcare programs.
3. Pregnant women who require immediate access to prenatal care.
4. Individuals who have recently lost their health insurance coverage due to circumstances such as job loss or aging out of dependent coverage.
5. Individuals experiencing a medical emergency or urgent health condition that requires immediate healthcare services.

Please note that the specific requirements and eligibility criteria for presumptive eligibility certification may vary depending on the healthcare agency or organization providing the program. It is recommended to contact the appropriate agency or seek guidance from a healthcare professional for accurate and up-to-date information.

For pdfFiller’s FAQs

What is presumptive eligibility certification and?

Presumptive eligibility certification is a process that allows certain individuals to receive temporary Medicaid coverage while their full eligibility is being determined.

Who is required to file presumptive eligibility certification and?

Health care providers, such as hospitals and clinics, are required to file presumptive eligibility certification for their patients.

How to fill out presumptive eligibility certification and?

Providers must gather the necessary information from the patient, verify their income and other eligibility criteria, and submit the application to the Medicaid agency.

What is the purpose of presumptive eligibility certification and?

The purpose of presumptive eligibility certification is to ensure that individuals who are likely eligible for Medicaid receive coverage quickly and without delay.

What information must be reported on presumptive eligibility certification and?

The application must include the individual's personal information, income details, household size, and any other required documentation.

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