Medicare Savings Programs Application/redetermination (Qmb, Slmb, Almb) (Page 3 of 6) in pdf

Medicare Savings Programs Application/redetermination (Qmb, Slmb, Almb) Page 3

I authorize the Department of Social Services to verify any information about anyone’s non-citizen status with the

United States Citizenship and Immigration Services (USCIS). I understand that the department will not share the

information I give on this form with USCIS. I also understand that USCIS cannot use this application to deny

admission to the U.S., harm permanent resident status or deport me.

I give the Department of Social Services permission to share my name and other information with programs that

help with energy costs for my home. These programs will use this information only to decide if I qualify for these

benefits and to offer me the benefits.

I give permission to the Department of Social Services, the Connecticut Medicaid Agency, or any health insurer,

provider, or any other entity providing services to me or my family under the Medicaid program to release

information about me or my family as necessary for the delivery of Medicaid program services and the

administration of the Medicaid program, as permissible by federal or state law.

I certify that all the statements made on this form are true and complete to the best of my knowledge. If I have

knowingly given incorrect information, I may be subject to the penalties for false statements as specified in

Connecticut General Statute Sections 53a-157b and 17b-97 and to penalties for larceny as specified in sections

53a-122 and 53a-123. I may also be subject to penalties for perjury under federal law.

Signature of Applicant

Date

Signature of Spouse

Date

Signature of Conservator or Other Representative

Date

Please be sure to read the important information on the back page of this form.

This information is available in alternate formats. Phone (800) 842-1508 OR TDD/TTY (800) 842-4524.

Medicare Savings Programs Application/redetermination (Qmb, Slmb, Almb) Page 3