Hospital Application for Presumptive Eligibility for Medicaid 
Page 1 of 2 
 
1    Tell us about yourself   (Primary household member)                                                          Gender:  Male  Female         
We ask for this information so that we can contact you about this application. 
 
Name (first, middle, last)                                                                                                      
Social Security Number (SSN) (Not required for PE determination) 
Date of Birth (MM/DD/YYYY) 
Home address (Indicate “NONE” if you do not have one)  
City, State, Zip code  
Mailing address (if different from home address)  
Phone number (if you have one) Email address (if you have one) 
2    Tell us about your family  
List the members of your immediate family who live with you. Include your spouse and your children under age 19 if 
they live with you. Do not list other relatives or friends even if they live with you.  
Name (first, middle, last) 
D.O.B. 
(MM/DD/YYYY) 
Social Security 
Number (SSN) 
(Not required for 
PE 
determination) 
Relationship 
to you 
 
Already 
has 
Medicaid?  
(Yes or No) 
Applying 
for PE?  
(Yes or No) 
U.S. 
Citizen, 
U.S. 
National, 
or eligible 
immigrant? 
(Yes or No) 
Resident of 
the 
Territory? 
(Yes or No) 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
3    Other questions 
Answer these questions for yourself and any family members listed in Section 2. Your answers will make it easier to 
find out if you and any family members qualify.  
Is anyone pregnant, even if she is not applying for presumptive eligibility for Medicaid?     Yes  No 
If yes, who? ....................................................................................................................................           
Expected due date? ………………………………………………                      How many babies does she expect? ...................... 
Application for Presumptive Eligibility for Medicaid 
 
Page 2 of 2 
 
Is anyone who is applying for presumptive eligibility for Medicaid a parent or caretaker relative?     Yes  No 
For example, a grandparent who is the main person taking care of a child. 
If yes, who? ..................................................................................................................... 
Is anyone who is applying for presumptive eligibility a former foster care child who is currently under the age of 
26?  
 Yes  No             If yes, who? ................................................................... ................................. 
What age did the claimant leave the foster care system? ........................................................... 
Was the Claimant enrolled on Medicaid at the time they aged out?       Yes  No              
4    Tell us about your family’s income 
Write the total income before taxes are taken out for all family members listed in Section 2. 
Job income For example, wages, salaries, and self-employment income. 
 
Amount $...................    Employer/Address....................................................................................................................   
 
How often? (check one)  Weekly  Biweekly  Monthly  Yearly         Hours …………….   Date began ............................. 
Other income For example, unemployment checks, alimony, or disability payments from the Social Security 
Administration (“SSDI”). Do not include any child support you receive. 
 
Amount $.....................   Type of Benefit .....................................................................................................................    
 
How often? (check one)  Weekly  Biweekly  Monthly  Yearly          Date began ........................................................ 
5    Sign this form here (optional) 
We will keep your information secure and private.  
Your signature (optional): 
Date: 
Hospital Representative Signature 
Date: