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The Florida DH 3212 form is a vital document for individuals seeking extended family planning benefits through a special Medicaid program. This application is specifically designed for those who have lost their full Medicaid coverage but still require assistance with family planning services. To begin the process, applicants must provide personal information, including their name, contact details, and residence. The form also includes important questions regarding reproductive history, such as previous surgeries like hysterectomies or tubal ligations, and the applicant's desire to receive family planning services. Additionally, the DH 3212 requires details about all household members, including their income sources, which helps determine eligibility based on federal poverty guidelines. Proof of U.S. citizenship and identity is essential, as is a signed certification that allows the Department of Health to access necessary medical and financial information. Completing this form accurately is crucial, as any omissions can delay the benefits determination process. Ultimately, the DH 3212 serves as a gateway to essential health services, empowering individuals to take control of their family planning needs.

⇓ Florida Dh 3212 File

Documents used along the form

The Florida DH 3212 form is essential for individuals seeking extended family planning benefits through Medicaid. However, there are several other documents that often accompany this form to ensure a comprehensive application process. Here’s a brief overview of these additional forms and documents.

  • Proof of U.S. Citizenship: This document verifies the applicant's citizenship status. Acceptable forms include a U.S. Passport, a U.S. Birth Certificate, or other official documents that confirm citizenship.
  • Income Verification Documents: These documents, such as recent pay stubs or tax returns, are necessary to demonstrate the applicant's income level. They help determine eligibility based on income guidelines.
  • Medicaid Denial Letter: If an applicant has previously been denied Medicaid coverage, this letter serves as proof of that denial. It is important for establishing the need for the Family Planning Waiver Program.
  • Health Insurance Information: This includes details about any existing health insurance coverage. Applicants must provide the name of their insurance company and specify if family planning is included as a benefit.
  • Authorization for Release of Information: This form allows healthcare providers and relevant agencies to share information about the applicant's health and financial status. It is crucial for coordinating care and processing claims.

Having these documents ready can streamline the application process and help ensure that individuals receive the benefits they need without unnecessary delays. Each document plays a vital role in verifying eligibility and facilitating access to essential family planning services.

Similar forms

The Florida DH 3212 form is similar to the Medicaid Application for Benefits (Form 1086). Both documents serve the purpose of assessing eligibility for health benefits under Medicaid programs. The Medicaid Application requires personal information, income details, and household composition, similar to the DH 3212. Each form emphasizes the importance of providing accurate information to ensure proper evaluation of eligibility for health services.

Another comparable document is the Food Assistance Application (Form 407). This application is used to determine eligibility for food assistance programs, requiring information about household income and expenses. Like the DH 3212, it focuses on the applicant's financial situation and household structure. Both forms aim to support individuals and families in accessing essential services, promoting overall well-being.

The Temporary Cash Assistance Application (Form 400) also shares similarities with the DH 3212. This form is designed to assess eligibility for cash assistance programs. It requires detailed information about the applicant's income and household members, paralleling the requirements of the DH 3212. Both documents are critical in connecting individuals to necessary financial support services, thereby helping them achieve stability.

The Child Care Assistance Application (Form 200) is another relevant document. It evaluates eligibility for child care subsidies, requiring information about family income and the number of children needing care. Like the DH 3212, it focuses on ensuring that families have access to vital resources that support their children's well-being and development. Both forms emphasize the importance of providing a safe and nurturing environment for children.

The Women, Infants, and Children (WIC) Program Application is also similar to the DH 3212. This application is intended for families seeking nutritional assistance and education. It requires income verification and household details, akin to the requirements outlined in the DH 3212. Both forms aim to improve health outcomes for vulnerable populations by providing access to essential services that promote healthy living.

Lastly, the KidCare Application shares characteristics with the DH 3212. This form is used to determine eligibility for children's health insurance coverage. It collects information about family income, household composition, and existing health insurance, similar to the DH 3212. Both applications play a crucial role in ensuring that children receive the health care they need, thereby supporting their overall growth and development.

Obtain Answers on Florida Dh 3212

  1. What is the Florida DH 3212 form?

    The Florida DH 3212 form is an application for the Health Insurance Application for Extended Family Planning Benefits. This special Medicaid program is designed to help individuals access family planning services. If you are eligible, this program can assist you in delaying pregnancy through various health services.

  2. Who is eligible to apply for the Family Planning Waiver program?

    To qualify for the Family Planning Waiver program, you must meet several criteria. You should not be pregnant and must not have undergone a hysterectomy or tubal ligation. Additionally, you need to have lost your full Medicaid coverage and have an income that is less than or equal to 185% of the current federal poverty level. If you meet these requirements, you can apply using the DH 3212 form.

  3. What information do I need to provide on the form?

    The DH 3212 form requires you to provide personal information such as your name, address, and phone number. You will also need to answer questions regarding your reproductive health history, including whether you have had a hysterectomy or tubal ligation. Furthermore, you must list all individuals living in your household, their relationship to you, and their income sources. Only the applicant is required to provide a Social Security Number and proof of citizenship.

  4. How do I submit the DH 3212 form?

    You can submit the completed DH 3212 form by mailing or bringing it to your local county health department. It’s important to note that you should not send this application directly to Medicaid. Make sure to include any required documentation, such as proof of citizenship and identity, to avoid delays in processing your application.

  5. What happens after I submit my application?

    Once you submit your application, the health department will review it to determine your eligibility for the Family Planning Waiver program. If additional information is needed, you may be contacted by phone. You will also receive a notification by mail regarding your eligibility status. It’s crucial to provide accurate and complete information to ensure a smooth process.

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Office Date Received

 

 

 

Health Insurance Application for Extended Family Planning Benefits

 

 

 

 

 

 

 

A Special Medicaid Program

 

 

 

 

 

 

 

 

 

 

 

 

 

Name:

First

M.I.

Last

Maiden Name

 

Area Code

Phone Number

 

 

 

 

 

 

 

(

)

 

 

Residence:

Number

Street

Apt. No.

City

County

 

State

Zip Code

 

 

 

 

 

Mailing Address (Required if different from above):

 

 

 

If no home phone, number where you can be

 

 

 

 

 

 

 

reached

 

(

)

Please answer the following questions:

 

 

 

 

 

 

 

 

1.

In the past, have you had one or both of the following services?

Hysterectomy: Yes

No Tubal ligation: Yes No

 

 

 

 

 

2.

What was the date of your last menstrual period? __________________ Yes No

 

 

 

 

 

 

3.

The benefits you will receive are intended to delay pregnancy through family planning services. Do you wish to receive these services? Yes No

 

 

 

4.List all of the people who live in your home (write your name first):

**Only the applicant must provide her Social Security Number and her proof of citizenship and identity.

First

M.I.

Last

 

Relationship to

 

**Social Security

 

Date of Birth

Race

Sex

US Citizen?

** If no, give INS

Date of

Applied for

 

 

 

 

 

 

Applicant

 

 

Number

 

 

 

 

 

Yes

No

ID Number

Entry

Medicaid?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

(Self)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

5. Income: Complete the following information on anyone in the home who gets money from any source (include your parents if you are under age 21 and live with them):

 

 

 

Name of Person

 

Income Source

 

 

Gross Income

 

How Often Are You Paid This Amount?

 

Additional Information

 

 

Receiving Income

 

 

 

 

 

(Before Deduction)

 

 

(weekly, biweekly, monthly)

 

 

 

 

 

 

 

 

 

Current Job: Employer’s Name

 

 

 

 

 

 

 

 

Employer’s Address/Phone Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current Job: Employer’s Name

 

 

 

 

 

 

 

 

Employer’s Address/Phone Number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Child Support

 

 

 

 

 

 

 

 

 

 

 

Child Care Cost for Job:

 

 

 

 

 

Contributions from Others

 

 

 

 

 

 

 

 

 

 

Paid by:

 

 

 

 

 

 

 

Unemployment Benefits

 

 

 

 

 

 

 

 

 

 

 

Paid to:

 

 

 

 

 

 

 

Social Security/SSI

 

 

 

 

 

 

 

 

 

 

 

Child(ren) paid for:

 

 

 

 

 

 

 

Other Income – List Type

 

 

 

 

 

 

 

 

 

 

 

Amt. Paid: $

How often:

6. Do you have health insurance? Yes No If yes, give the name of the insurance company: _________________________________

 

 

 

 

7.

If you are 18 or under, are you enrolled in any KidCare program? Yes No

 

 

 

 

 

 

 

 

 

 

 

 

8.

If yes, does your insurance have family planning as a benefit?

Yes No

 

 

 

 

 

 

 

 

 

 

 

 

9.Please attach proof of US citizenship and identity to this application. Evidence of U.S. citizenship includes but is not limited to: a U.S. Passport, a U.S. Birth Certificate, Form FS-240, Report of Birth Abroad of a Citizen of the U.S. or Form FS 545 or From DS1350, Certification of Birth Abroad. Only originals or certified copies are acceptable.

CERTIFICATION AND AUTHORIZATION: I certify that the information provided on this application is true and correct to the best of my knowledge. By signing this form, I give consent to the Department of Health to obtain and to release my confidential financial and medical information for the purpose of determining eligibility for the Family Planning Waiver Program. I therefore authorize the following programs under Medicaid, MomCare, WIC, and DCF or their agents to contact me or my healthcare provider(s) for the purpose of coordination of care, payment of claims for services, quality improvement of services concerning my participation in the family planning waiver program. My authorization to release information includes any medical, mental health, alcohol/drug abuse, sexually transmitted disease, tuberculosis, HIV/AIDS, and adult or child abuse information. I understand that the information I have provided shall be kept confidential in accordance with Florida and federal laws. I have read and understand my rights and responsibilities as they apply to the family planning waiver program and that authorization shall remain in effect unless withdrawn in writing.

Signature of Applicant:

 

Date:

 

Eligibility Staff Signature/Date:

 

FMMIS Termination Date:

 

 

 

 

 

 

Mail or bring this application and any letter you received to your local county health department (see attached list). DO NOT SEND THIS APPLICATION TO MEDICAID.

DH 3212, 11/06 Stock No. 5744-000-3212-0

Florida Department of Health Instructions for Completing the

Health Insurance Application for Extended Family Planning Benefits

(Medicaid Family Planning waiver)

The information on the application is needed to help determine if you are approved for the Medicaid Family Planning Waiver program. You are eligible for this program if you have:

Lost your full Medicaid

Have not had a hysterectomy or tubal ligation.

Not pregnant.

Desires family planning services.

Income is less than or equal to 185% current federal poverty level.

In order to assist with this determination we need you to complete the application, answer the questions (1-9) and sign and date the form. Failure to complete the application will delay the determination for benefits as well as your duration or time on this program, if eligible. You must sign and date the form after the date that you lost your full Medicaid.

Fill in the rows starting with Name, Residence and Mailing Address. Please print your information. Please complete or fill in the information requested in these rows on the form. Please include your mailing address if different from your residence (home) address. This contact information is important. You will be contacted by phone if additional information is needed; you will be contacted by mail to let you know about your eligibility for the program.

Questions 1-3 ask for your reproductive history and whether you desire to participate in the Family Planning Waiver program. Please answer questions 1 through 3.

Question 4 asks for a list of all of the people who live with you or live in your home. Please complete the information requested of yourself as well as the other people or persons that live with you or in your home. Please note that only you, the applicant will need to provide your:

social security number

certified proof of your citizenship and identity, if claiming to be a U.S. Citizen and

proof of your income, pay stubs from the last four weeks, if employed.

Question number 5 asks for the name, income sources, and relationship for not only yourself but the people living with you or in your home. Please complete the information requested of yourself as well as the other people or persons that live with you or in your home including current job, employer’s address and phone number.

Please fill out the column with the heading Child Care Cost for Job.

Questions 6-8 ask for insurance information. Please answer questions 6-8

Read the Certification and Authorization section and sign and date the form. You need to mail or bring this application to your local health department.

DH 3212

Dos and Don'ts

When filling out the Florida DH 3212 form, it is essential to follow specific guidelines to ensure a smooth application process. Here are eight key dos and don'ts to consider:

  • Do provide accurate personal information, including your full name, address, and contact details.
  • Don't leave any sections blank. Incomplete information can delay your application.
  • Do answer all questions regarding your reproductive history honestly and completely.
  • Don't forget to include your Social Security Number and proof of citizenship; these are mandatory for the applicant.
  • Do list all individuals living in your household, including their relationship to you.
  • Don't provide false information about your income or living situation, as this can result in denial of benefits.
  • Do sign and date the form after you have completed it, ensuring your application is valid.
  • Don't send the application to Medicaid; instead, deliver it to your local county health department.