Medicare Savings Programs Application/redetermination (Qmb, Slmb, Almb) (Page 4 of 6) in pdf

If you need a reasonable accommodation or special help:

If you cannot do something we ask you to do because you have a disability, you may request a reasonable

accommodation or special help. We can use different methods to complete your application or redetermination.

For example, we may be able to complete your application or redetermination over the telephone if you cannot

come into the office, we may be able to help you get certain proofs, or give you extra time to provide information.

Contact your local regional office to request a reasonable accommodation or special help. If we do not agree to

give you a reasonable accommodation or special help, you can complain to the department’s Americans with

Disabilities Act (ADA) coordinator. See the bottom of this page for how to make a complaint.

Important information for you to know about your application/redetermination:



This application/redetermination is a request for help from the Medicare Savings Programs only.



All the information given on this form is confidential and will only be used to administer the programs except for

certain exceptions.



The Social Security numbers of everyone receiving or requesting assistance will be used to verify identity and

eligibility. Social Security numbers will also be matched against federal, state and local government files by

computer. The department is allowed to request Social Security numbers based on the following statutes: for

Medicaid, 42 USC sections 1320b-7(a)(1), (b)(2) and Connecticut General Statutes section 17b-77.



The department will request information through the Income and Eligibility Verification System (IEVS). The

information will be used to process this application/redetermination. Information will come from certain State

and Federal agencies when allowed by law. We may directly verify information we receive with other sources

such as banks and employers. Results from such verification may affect eligibility.

In accordance with Federal law and U.S. Department of Health and Human Services (HHS) policy, the Department

of Social Services is prohibited from discriminating on the basis of race, color, national origin, sex, age or disability.

To file a complaint of discrimination, write HHS, Director, Office for Civil Rights, 200 Independence Avenue, S.W.,

Room 509-F, HHH Building, Washington, D.C. 20201 or call (202) 619-0403 (voice) or (202) 619-3257 (TTY).

Under state law you have the right to make a discrimination complaint if you think we have taken actions against

you because of your race, color, religious creed, sex, marital status, age, national origin, ancestry, criminal record,

political beliefs, sexual orientation, mental retardation, mental disability, learning disability or physical disability,

including but not limited to blindness. You or someone representing you may write to or call one or more of these

agencies to make a discrimination complaint: Commissioner of the Department of Social Services, Attention

Affirmative Action Division Director/ADA Coordinator, 25 Sigourney Street, Hartford, CT 06106-5033, or call

1-860-424-5040 (TDD: 1-800-842-4524); Connecticut Commission on Human Rights and Opportunities, 21

Grand Street, Hartford, CT 06106, or call 1-860-541-3400 (TDD: 1-860-541-3459).

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