Medicaid Program Current, Past, Or Anticipated Wage Verification - Louisiana Department Of Health Page 2

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1. Name of Employee
Social Security No.
Address of Employee
Name of Employer
Date Started
Expected to Start
2. If terminated, give: Reason
Last Day Worked
Amount of Last Check $
3. Check how often the employee is (was or will be) paid and complete the chart below (as indicated in
the corresponding parentheses:
Weekly (Show 4 most recent)
Twice Monthly (Show 2 most recent)
Every Two Weeks (Show 2 most recent)
Monthly (Show 1 most recent)
Date Wages
Number of Hours
Gross pay Before
Period Ending
Earned Income
Received OR
Worked OR
Deductions OR
(Not applicable to
Tax Credit Paid
Anticipated Wages)
Anticipated
Anticipated
Anticipated Pay
$
$
$
$
$
$
$
$
4. If employment is new, please provide:
# hours expected to work
$
hourly rate of pay
how often paid.
5. Are you aware of any other income this person may be receiving, such as other wages, compensation
or pensions?
Yes
No
If yes, please indicate the source:
6. Is/was employee covered by health insurance?
Yes
No If yes, please provide:
Name of insurance company
Claims filing address
Policy No.
Date of entitlement
Type of coverage
(group, hospital, major medical)
Who is/was covered?
(
)
Signature of Employer
Date
Telephone Number

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