Fillable Applicaon for Medicaid and Aordable Health Coverage

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Applicaon for Medicaid and Aordable Health Coverage

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The Applicaon for Medicaid and Aordable Health Coverage form is 22 pages long and contains:

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  • 530 check-boxes
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Country of origin: US
File type: PDF

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NEED HELP WITH YOUR APPLICATION? Visit SCDHHS.gov or call us at 1-888-549-0820. Para obtener una copia de este formulario
en Español, llame 1-888-549-0820. If you need help in a language other than English, call 1-888-549-0820 and tell the customer service
representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-888-842-3620.
DHHS Form 3400 (Aug. 2020)
Page 1 of 13
Application for Medicaid and Aordable Health Coverage
things to know
Use this application
to see what
coverage choices
you qualify for
• Aordableprivatehealthinsuranceplansthatoer
comprehensivecoveragetohelpyoustaywell.
• Anewtaxcreditthatcanimmediatelyhelppayyourpremiumfor
healthcoverage.
• Freeorlow-costinsurancefromMedicaidortheChildren’sHealth
InsuranceProgram(CHIP).
You may qualify for a free or low-cost program even if you
earn as much as $94,000 a year (for a family of 4).
Applicaon for Medicaid
and Aordable Health Coverage
Apply faster online
• ApplyfasteronlineatSCDHHS.govorHealthCare.gov.
What you may
need to apply
• SocialSecurityNumbers(ordocumentnumbersforany
legalimmigrantswhoneedinsurance)
• Employerandincomeinformationforeveryoneinyour
family(forexample,frompaystubs,W-2forms,orwageand
taxstatements)
• Policynumbersforanycurrenthealthinsurance
• Informationaboutanyjob-relatedhealthinsuranceavailable
toyourfamily
Why do we ask for
this information?
Weaskaboutincomeandotherinformationtoletyouknow
whatcoverageyouqualifyforandhowtogetanyhelppaying
forit.We’ll keep all the information you provide private
and secure, as required by law.ToviewthePrivacyAct
Statement,gotohttps://www.SCDHHS.gov/internet/pdf/
SCDHHSNoticeofPrivacyPractices080107.pdf.
What happens next?
Sendyourcomplete,signedapplicationtotheaddressonthe
signaturepage.
If you don’t have all the information we ask for, sign and
submit your application anyway. We’llfollow-upwithyou
within1–2weeks.You’llgetinstructionsonthenextstepsto
completeyourapplicationforhealthcoverage.Ifyoudon’thear
fromus,visitSCDHHS.govorcall1-888-549-0820.
Fillingoutthisapplicationdoesn’tmeanyouhavetobuyhealth
coverage.
NEED HELP WITH YOUR APPLICATION? Visit SCDHHS.gov or call us at 1-888-549-0820. Para obtener una copia de este formulario
en Español, llame 1-888-549-0820. If you need help in a language other than English, call 1-888-549-0820 and tell the customer service
representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-888-842-3620.
DHHS Form 3400 (Aug. 2020)
Page 2 of 13
Application for Medicaid and Aordable Health Coverage
Get help with this
application
• Online: SCDHHS.gov
• Phone: CallourHelpCenterat1-888-549-0820.
• In person:Theremaybecounselorsinyourareawhocan
help.
Visit our websiteorcall1-888-549-0820formore
information.
• En Español:Llameanuestrocentrodeayudagratisal
1-888-549-0820.
Tell us about
yourself
and your family.
Who do you need to include on this application?
Tellusaboutallthefamilymemberswholivewithyou.
Ifyouletaxes,weneedtoknowabouteveryoneon
yourtaxreturn.(Youdon’tneedtoletaxestoget
healthcoverage.)
DO include:
• Yourself
• Yourspouse
• Yourchildrenunder21wholivewithyou
• Yourunmarriedpartnerwhoneedshealth
coverage
• Anyoneyouincludeonyourtaxreturn,evenif
theydon’tlivewithyou
• Anyoneelseunder21whoyoutakecareof
andliveswithyou
You DON’T have to include:
• Yourunmarriedpartnerwhodoesn’tneed
healthcoverage
• Yourunmarriedpartner’schildren
• Yourparentswholivewithyou,butletheir
owntaxreturn(ifyou’reover21)
• Otheradultrelativeswholetheirowntax
return
Theamountofassistanceortypeofprogramyouqualifyfor
dependsonthenumberofpeopleinyourfamilyandtheir
incomes.Thisinformationhelpsusmakesureeveryonegets
thebestcoveragetheycan.
Who can use this
application?
• Usethisapplicationtoapplyforanyoneinyourfamily.
• Applyevenifyouoryourchildalreadyhashealthcoverage.
Youcouldbeeligibleforlower-costorfreecoverage.
• Ifyou’resingle,youmaybeabletouseashortform.
Visit HealthCare.gov.
• Familiesthatincludeimmigrantscanapply.Youcanapply
foryourchildevenifyouaren’teligibleforcoverage.
Applyingwon’taectyourimmigrationstatusorchancesof
becomingapermanentresidentorcitizen.
• Ifsomeoneishelpingyoulloutthisapplication,youmay
needtocompletetheAuthorizedRepresentativeForm
(1282),whichcanbedownloadedatSCDHHS.gov.
NEED HELP WITH YOUR APPLICATION? Visit SCDHHS.gov or call us at 1-888-549-0820. Para obtener una copia de este formulario
en Español, llame 1-888-549-0820. If you need help in a language other than English, call 1-888-549-0820 and tell the customer service
representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-888-842-3620.
DHHS Form 3400 (Aug. 2020)
Page 3 of 13
Application for Medicaid and Aordable Health Coverage
1. Firstname,Middlename,LastnameandSux
2. Homeaddress(Leaveblankifyoudon’thaveone.) 3. Apartmentorsuitenumber
4. City 5. State 6. ZIPcode 7. County
8. Mailingaddress(ifdierentfromhomeaddress) 9. Apartmentorsuitenumber
10. City 11. State 12. ZIPcode 13. County
14. Phonenumber 15. Otherphonenumber
16. Doyouwanttogetinformationaboutthisapplicationbyemail? Yes
No
Emailaddress:
17. Whatisyourpreferredspokenorwrittenlanguage(ifnotEnglish)?
Is someone helping you ll out this application?
Completethefollowingsectionifyouarellingoutthisformonbehalfoftheapplicant.
1. Applicationstartdate 2. Firstname,Middlename,Lastname,&Sux
3. OrganizationName(ifapplicable) 4. IDNumber(ifapplicable)
Start with yourself, then add other adults and children. If you have more than 4 people in your family, you’ll
need to make a copy of the pages and attach them. You don’t need to provide immigration status or a Social
Security Number (SSN) for family members who don’t need health coverage. We’ll keep all the information
you provide private and secure as required by law. We’ll use personal information only to check if you’re
eligible for health coverage. We need one adult in the family to be the contact person for your application.
Primary contact person
Haveaphysicalorintellectualdisability
Age65orolder
ReceiveMedicare
ApplyingforPCSCWaiver
ApplyingforTEFRA
Needtoliveinamedicalfacilityornursinghome
orneednursingservicesathome
Receivingtreatmentforoneofthefollowing:
-Breastcancer-Cervicalcancer-AtypicalBreastHyperplasia
-PrecancerousCervicalLesion(CIN2/3)
SSIisendingandneedtoreapplyforMedicaid(example:aletter
citingthePickleAmendment)
ForeignrefugeewhohasbeengrantedasylumintheU.S.
needs. If anyone applying for coverage meets the following criteria, please check all boxes that apply. Even if you or your
household members do not meet any of these criteria, you may still qualify for Medicaid. If none apply, do not check
anything; we will evaluate you for all available coverage types.
This box for pilot use onlyPresumptiveDisability
STEP 1
Some Medicaid programs that cover specic services require additional information to determine
eligibility.Bycompletingthissection,wewillbeabletoaskyouforinformationmostrelevanttoyour
NEED HELP WITH YOUR APPLICATION? Visit SCDHHS.gov or call us at 1-888-549-0820. Para obtener una copia de este formulario
en Español, llame 1-888-549-0820. If you need help in a language other than English, call 1-888-549-0820 and tell the customer service
representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-888-842-3620.
DHHS Form 3400 (Aug. 2020)
Page 4 of 13
Application for Medicaid and Aordable Health Coverage
STEP 1: PERSON 1
CompleteStep1foryourself,yourspouse/partnerandchildrenwholivewithyouand/oranyoneonyoursamefederalincome
taxreturnifyouleone.Seetheinstructionsformoreinformationaboutwhomtoinclude.Ifyoudon’tleataxreturn,remem-
bertostilladdfamilymemberswholivewithyou.
1. Firstname,Middlename,Lastname,&Sux 2. Relationshiptoyou?
3. Dateofbirth(mm/dd/yyyy) 4. Sex: Male5. SocialSecuritynumber(SSN)
Female
We need this if you want health coverage and have an SSN.ProvidingyourSSNcanbehelpfulifyoudon’twanthealthcoveragesinceitcan
speeduptheapplicationprocess.WeuseSSNstocheckincomeandotherinformationtoseewho’seligibleforhelpwithhealth
coveragecosts.IfsomeonewantshelpgettinganSSN,call1-800-772-1213orvisitsocialsecurity.gov.TTYusersshouldcall1-888-842-3620.
6. Do you plan to le a federal income tax return NEXT YEAR?
(Youcanstillapplyforhealthinsuranceevenifyoudon’tleafederalincometaxreturn.)
YES.Ifyes,pleaseanswerquestionsa–c. NO.Ifno,SKIPtoquestionc.
a. Willyoulejointlywithaspouse? Yes NoIfyes,nameofspouse:
b. Willyouclaimanydependentsonyourtaxreturn? Yes No
Ifyes,listdependents:
c. Willyoubeclaimedasadependentonsomeone’staxreturn? Yes No
Ifyes,pleaselistthetaxler: Howareyourelatedtothetaxler?
7. Areyoupregnantorrecentlypregnant? Yes NoIfyes,a.Howmanybabiesareexpected? b. Whatisyourduedate?
c. Ifrecentlypregnant,enterthedatethepregnancyended:
d. WereyouenrolledinMedicaidonthelastdayofpregnancy?
Yes No
8. Do you need health coverage? (Even if you have insurance, there might be a program with better coverage or lower costs.)
YES.Ifyes,answerallthequestionsbelow. NO.Ifno,SKIPtotheincomequestions.Leavetherestofthispageblank.
9. Doyouhaveadisablingphysical,mental,oremotionalhealthconditionthatcauseslimitationsinactivities? Yes No
10. Doyouneedtoliveinamedicalfacilityornursinghomeorneednursingservicesathome? Yes No
11. Haveyoubeendiagnosedwithandarereceivingtreatmentforanyofthefollowing? Yes No
•BreastCancer •CervicalCancer •AtypicalBreastHyperplasia •PrecancerousCervicalLesion(CIN2/3)
12. DoyouwanttoapplyforFamilyPlanningbenets? Yes No
Family Planning is a limited benet program, which provides family planning services, family planning-related services and certain limited
preventative screenings. Family Planning is not full Medicaid coverage. If you leave this question blank, we will not assess you for Family Planning.
13.a.AreyouaU.S.citizen?(BorninU.S.;childofU.S.citizen;orformeraliennownaturalizedasaU.S.citizen)
Yes No
b. AreyouaU.S.national?(BorninunincorporatedU.S.Territorywhoelectstobeanational,notaU.S.citizen) Yes No
14. If you aren’t a U.S. citizen or U.S. national, do you have eligible immigration status? Yes No
IfYES,llinyourdocumenttypeandIDnumberbelow.
a. Immigrationdocumenttype: b. DocumentIDnumber:
c. HaveyoulivedintheU.S.since1996? Yes No
d. Areyou,oryourspouseorparentaveteranoranactive-dutymemberoftheU.S.military? Yes No
15. IfyouhavenotappliedforaSocialSecurityNumber,listthereason:
Issuedfornon-workreasonsonly  NoSSNduetoreligiousreasons
NoteligibleforSSN
Newborn,mothercurrentlyreceivingMedicaid
Newborn,motherNOTreceivingMedicaid
16. Doyouwanthelppayingformedicalbillsfromthelast3months? Yes No
17. Doyoulivewithatleastonechildundertheageof19,andareyouthemainpersontakingcareofthischild? Yes No
18. Areyouafull-timestudent? Yes No
19. WereyouinfostercareinSouthCarolinaatage18orolder? Yes No
20. Areyoucurrentlylivinginafosterhome? Yes No
21. AreyoucurrentlylivinginaDJJgrouphome? Yes No
SELF
a. Ifyoudon’thaveaSSN,haveyouappliedfor
one?
Yes No
If no, indicate the reason at
question 15.
b. Wasyourhouseholdincomethesameduringthese3monthsasitisnow?
Yes No
IfNO,enterthetotalmonthlyincomefor:LastMonth:$ 2
MonthsAgo:$ 3 MonthsAgo:$
a. IfYES,wasyourhouseholdsizethesameduringthese3monthsasitisnow?
Yes No
Complete Step 1 for each person in your family.
Start with information about yourself.
Now, tell us about any income from on the next page.
NEED HELP WITH YOUR APPLICATION? Visit SCDHHS.gov or call us at 1-888-549-0820. Para obtener una copia de este formulario
en Español, llame 1-888-549-0820. If you need help in a language other than English, call 1-888-549-0820 and tell the customer service
representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-888-842-3620.
DHHS Form 3400 (Aug. 2020)
Page 5 of 13
Application for Medicaid and Aordable Health Coverage
STEP 1: PERSON 1
(Continue with yourself)
Current job & income information
Employed
Ifyou’recurrentlyemployed,tellusabout
yourincome.Startwithquestion24.
Not Employed
SKIPtoquestion36.
Self-Employed
SKIPtoquestion35.
CURRENT JOB 1:
24. Employernameandaddress 25. Employerphonenumber
26. Wages/tips(beforetaxes)
Hourly Weekly Every2weeks Twiceamonth Monthly Yearly
$ 27. Averagehoursworkedeachweek 28. Startdate
CURRENT JOB 2:(Ifyouhavemorejobsandneedmorespace,attachanothersheetofpaper)
29. Employernameandaddress 30. Employerphonenumber
31. Wages/tips(beforetaxes)
Hourly Weekly Every2weeks Twiceamonth Monthly Yearly
$ 32. Averagehoursworkedeachweek 33. Startdate
34. In the past year, did you: Changejobs Stopworking Startworkingfewerhours Noneofthese
35. If self-employed, answer the following questions:
a. Typeofwork b.Howmuchnetincome(protsoncebusinessexpensesarepaid
willyougetfromthisself-employmentthismonth?)
$
36. OTHER INCOME THIS MONTH:Checkallthatapply,andgivetheamountandhowoftenyougetit.
NOTE: Youdon’tneedtotellusaboutchildsupport,veteran’spaymentsorSupplementalSecurityIncome(SSI).
None
Unemployment $ Howoften? Netfarming/shing: $ Howoften?
Pensions $ Howoften? Netrental/royalty: $ Howoften?
SocialSecurity $ Howoften? Otherincome:
Retirementacc’ts$ Howoften? Type: $ Howoften?
Alimonyreceived$ Howoften?
Type: $ Howoften?
37. DEDUCTIONS: Checkallthatapply,andgivetheamountandhowoftenyougetit.
IfPERSON1paysforcertainthingsthatcanbedeductedonafederalincometaxreturn,tellingusaboutthemcouldmakethecostofhealth
coveragealittlelower.
NOTE: Youshouldn’tincludeacostthatyoualreadyconsideredinyouranswertonetself-employment.
Alimonypaid $ Howoften?
Otherdeductions: $ Howoften?
Studentloaninterest $ Howoften? Type:
38. YEARLY INCOME: Complete only if PERSON 1’s income changes from month to month.
If you don’t expect changes to PERSON 1’s monthly income, add another person on the following pages.
PERSON1’stotalincomethisyear PERSON1’stotalincomenextyear(ifyouthinkitwillbedierent)
$ $
THANKS! This is all we need to know about you.
23. Race (OPTIONAL—check all that apply)
White
AmericanIndianorAlaskanative
Vietnamese
Filipino
Black/AfricanAmerican
GuamanianorChamorro
Japanese AsianIndian
Samoan
OtherAsianChinese
Korean
OtherPacicIslander
Other:
NativeHawaiian
Mexican Mexican-American Chicano/a PuertoRican
Cuban Other:
22. If Hispanic/Latino, ethnicity (OPTIONAL)
NEED HELP WITH YOUR APPLICATION? Visit SCDHHS.gov or call us at 1-888-549-0820. Para obtener una copia de este formulario
en Español, llame 1-888-549-0820. If you need help in a language other than English, call 1-888-549-0820 and tell the customer service
representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-888-842-3620.
DHHS Form 3400 (Aug. 2020)
Page 6 of 13
Application for Medicaid and Aordable Health Coverage
STEP 1: PERSON 2
CompleteStep1foryourspouse/partnerandchildrenwholivewithyouand/oranyoneonyoursamefederalincometaxreturn
ifyouleone.Seetheinstructionsformoreinformationaboutwhomtoinclude.Ifyoudon’tleataxreturn,remembertostill
addfamilymemberswholivewithyou.
1. Firstname,Middlename,Lastname,&Sux 2. Relationshiptoyou?
3. Dateofbirth(mm/dd/yyyy) 4. Sex: Male Female 5. SocialSecuritynumber(SSN)
6. DoesPERSON2liveatthesameaddressasyou? Yes No
Ifno,listaddress:
7. Does Person 2 plan to le a federal income tax return NEXT YEAR?
(Youcanstillapplyforhealthinsuranceevenifyoudon’tleafederalincometaxreturn.)
YES.Ifyes,pleaseanswerquestionsa–c. NO.Ifno,SKIPtoquestionc.
a. WillPerson2lejointlywithaspouse? Yes NoIfyes,nameofspouse:
b. WillPerson2claimanydependentsonyourtaxreturn? Yes No
Ifyes,listdependents:
c. WillPerson2beclaimedasadependentonsomeone’staxreturn? Yes No
Ifyes,pleaselistthetaxler: Howareyourelatedtothetaxler?
8. Areyoupregnantorrecentlypregnant? Yes NoIfyes,a.Howmanybabiesareexpected? b. Whatisyourduedate?
c. Ifrecentlypregnant,enterthedatethepregnancyended:
d. WereyouenrolledinMedicaidonthelastdayofpregnancy? Yes No
9. Does PERSON 2 need health coverage? (Even if you have insurance, there might be a program with better coverage or lower costs)
YES.Ifyes,answerthequestionsbelow. NO.Ifno,SKIPtotheincomequestions.Leavetherestofthispageblank.
10. Doyouhaveadisablingphysical,mental,oremotionalhealthconditionthatcauseslimitationsinactivities? Yes No
11. Doyouneedtoliveinamedicalfacilityornursinghomeorneednursingservicesathome? Yes No
12. Haveyoubeendiagnosedwithandarereceivingtreatmentforanyofthefollowing? Yes No
•BreastCancer •CervicalCancer •AtypicalBreastHyperplasia •PrecancerousCervicalLesion(CIN2/3)
13. DoesPERSON2wanttoapplyforFamilyPlanningbenets? Yes No
Family Planning is a limited benet program, which provides family planning services, family planning-related services and certain limited
preventative screenings. Family Planning is not full Medicaid coverage. If you leave this question blank, we will not assess you for Family Planning.
14.a.IsPERSON2aU.S.citizen?(BorninU.S.;childofU.S.citizen;orformeraliennownaturalizedasaU.S.citizen)
Yes No
b. IsPERSON2aU.S.national?(BorninunincorporatedU.S.Territorywhoelectstobeanational,notaU.S.citizen) Yes No
15. If PERSON 2 isn’t a U.S. citizen or U.S. national, does PERSON 2 have eligible immigration status? Yes No
IfYES,llinPERSON2’sdocumenttypeandIDnumberbelow.
a. Immigrationdocumenttype:
b. DocumentIDnumber:
c. HasPERSON2livedintheU.S.since1996? Yes No
d. IsPERSON2,theirspouseorparentaveteranoranactive-dutymemberoftheU.S.military? Yes No
16. IfyouhavenotappliedforaSocialSecurityNumber,listthereasons
Issuedfornon-workreasonsonly  NoSSNduetoreligiousreasons
No te lig ibl ef or SSN
Newborn,mothercurrentlyreceivingMedicaid Newborn,motherNOTreceivingMedicaid
17. DoesPERSON2wanthelppayingformedicalbillsfromthelast3months? Yes No
18. DoesPERSON2livewithatleastonechildunder19,andisPERSON2themainpersontakingcareofthischild? Yes No
19. IsPERSON2afull-timestudent? Yes No
20. WasPERSON2infostercareinSouthCarolinaatage18orolder? Yes No
21. IsPERSON2currentlylivinginafosterhome? Yes No
22. IsPERSON2currentlylivinginaDJJgrouphome? Yes No
Now, tell us about any income from PERSON 2 on the next page.
a. Ifyoudon’thaveaSSN,have
youappliedforone?
Yes No
If no, indicate the reason at
question 16.
We need this if PERSON 2 wants health
coverage and has an SSN.
b. Wasthisperson’shouseholdincomethesameduringthese3monthsasitisnow?
Yes No
IfNO,enterthetotalmonthlyincomefor:LastMonth:$ 2
MonthsAgo:$ 3 MonthsAgo:$
a. IfYES,wasthisperson’shouseholdsizethesameduringthese3monthsasitisnow?
Yes No
NEED HELP WITH YOUR APPLICATION? Visit SCDHHS.gov or call us at 1-888-549-0820. Para obtener una copia de este formulario
en Español, llame 1-888-549-0820. If you need help in a language other than English, call 1-888-549-0820 and tell the customer service
representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-888-842-3620.
DHHS Form 3400 (Aug. 2020)
Page 7 of 13
Application for Medicaid and Aordable Health Coverage
STEP 1: PERSON 2
Current job & income information
Employed
Ifyou’recurrentlyemployed,tellusabout
yourincome.Startwithquestion25.
Not Employed
SKIPtoquestion37.
Self-Employed
SKIPtoquestion36.
CURRENT JOB 1:
25. Employernameandaddress 26. Employerphonenumber
27. Wages/tips(beforetaxes)
Hourly Weekly Every2weeks Twiceamonth Monthly Yearly
$ 28. Averagehoursworkedeachweek 29. Startdate
CURRENT JOB 2:(Ifyouhavemorejobsandneedmorespace,attachanothersheetofpaper)
30. Employernameandaddress 31. Employerphonenumber
32. Wages/tips(beforetaxes)
Hourly Weekly Every2weeks Twiceamonth Monthly Yearly
$ 33. Averagehoursworkedeachweek 34. Startdate
35. In the past year, did you: Changejobs Stopworking Startworkingfewerhours Noneofthese
36. If self-employed, answer the following questions:
a. Typeofwork b.Howmuchnetincome(protsoncebusinessexpensesarepaid
willyougetfromthisself-employmentthismonth?)
$
37. OTHER INCOME THIS MONTH:Checkallthatapply,andgivetheamountandhowoftenyougetit.
NOTE: Youdon’tneedtotellusaboutchildsupport,veteran’spaymentsorSupplementalSecurityIncome(SSI).
None
Unemployment $ Howoften? Netfarming/shing: $ Howoften?
Pensions $ Howoften? Netrental/royalty: $ Howoften?
SocialSecurity $ Howoften? Otherincome:
Retirementacc’ts$ Howoften? Type: $ Howoften?
Alimonyreceived$ Howoften?
Type: $ Howoften?
38. DEDUCTIONS: Checkallthatapply,andgivetheamountandhowoftenyougetit.
IfPERSON2paysforcertainthingsthatcanbedeductedonafederalincometaxreturn,tellingusaboutthemcouldmakethecostofhealth
coveragealittlelower.
NOTE: Youshouldn’tincludeacostthatyoualreadyconsideredinyouranswertonetself-employment.
Alimonypaid $ Howoften?
Otherdeductions: $ Howoften?
Studentloaninterest $ Howoften? Type:
39. YEARLY INCOME: Complete only if PERSON 2’s income changes from month to month.
If you don’t expect changes to PERSON 2’s monthly income, add another person on the following pages.
PERSON2’stotalincomethisyear PERSON2’stotalincomenextyear(ifyouthinkitwillbedierent)
$ $
24. Race (OPTIONAL—check all that apply)
White
AmericanIndianorAlaskanative
Vietnamese
Filipino
Black/AfricanAmerican
GuamanianorChamorro
Japanese AsianIndian
Samoan
OtherAsianChinese
Korean
OtherPacicIslander
Other:
NativeHawaiian
Mexican Mexican-American Chicano/a PuertoRican
Cuban Other:
23. If Hispanic/Latino, ethnicity (OPTIONAL)
NEED HELP WITH YOUR APPLICATION? Visit SCDHHS.gov or call us at 1-888-549-0820. Para obtener una copia de este formulario
en Español, llame 1-888-549-0820. If you need help in a language other than English, call 1-888-549-0820 and tell the customer service
representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-888-842-3620.
DHHS Form 3400 (Aug. 2020)
Page 8 of 13
Application for Medicaid and Aordable Health Coverage
STEP 1: PERSON 3
CompleteStep1foryourspouse/partnerandchildrenwholivewithyouand/oranyoneonyoursamefederalincometaxreturn
ifyouleone.Seetheinstructionspageformoreinformationaboutwhomtoinclude.Ifyoudon’tleataxreturn,rememberto
stilladdfamilymemberswholivewithyou.
1. Firstname,Middlename,Lastname,&Sux 2. Relationshiptoyou?
3. Dateofbirth(mm/dd/yyyy) 4. Sex: Male Female 5. SocialSecuritynumber(SSN)
6. DoesPERSON3liveatthesameaddressasyou? Yes No
Ifno,listaddress:
7. Does Person 3 plan to le a federal income tax return NEXT YEAR?
(Youcanstillapplyforhealthinsuranceevenifyoudon’tleafederalincometaxreturn.)
YES.Ifyes,pleaseanswerquestionsa–c. NO.Ifno,SKIPtoquestionc.
a. WillPerson3lejointlywithaspouse? Yes NoIfyes,nameofspouse:
b. WillPerson3claimanydependentsonyourtaxreturn? Yes No
Ifyes,listdependents:
c. WillPerson3beclaimedasadependentonsomeone’staxreturn? Yes No
Ifyes,pleaselistthetaxler: Howareyourelatedtothetaxler?
8. Areyoupregnantorrecentlypregnant? Yes NoIfyes,a.Howmanybabiesareexpected? b. Whatisyourduedate?
c. Ifrecentlypregnant,enterthedatethepregnancyended:
d. WereyouenrolledinMedicaidonthelastdayofpregnancy? Yes No
9. Does PERSON 3 need health coverage? (Even if you have insurance, there might be a program with better coverage or lower costs)
YES.Ifyes,answerthequestionsbelow. NO.Ifno,SKIPtotheincomequestionsonpage7.Leavetherestofthispageblank.
10. Doyouhaveadisablingphysical,mental,oremotionalhealthconditionthatcauseslimitationsinactivities? Yes No
11. Doyouneedtoliveinamedicalfacilityornursinghomeorneednursingservicesathome? Yes No
12. Haveyoubeendiagnosedwithandarereceivingtreatmentforanyofthefollowing? Yes No
•BreastCancer •CervicalCancer •AtypicalBreastHyperplasia •PrecancerousCervicalLesion(CIN2/3)
13. DoesPERSON3wanttoapplyforFamilyPlanningbenets? Yes No
Family Planning is a limited benet program, which provides family planning services, family planning-related services and certain limited
preventative screenings. Family Planning is not full Medicaid coverage. If you leave this question blank, we will not assess you for Family Planning.
14.a.IsPERSON3aU.S.citizen?(BorninU.S.;childofU.S.citizen;orformeraliennownaturalizedasaU.S.citizen)
Yes No
b. IsPERSON3aU.S.national?(BorninunincorporatedU.S.Territorywhoelectstobeanational,notaU.S.citizen) Yes No
15. If PERSON 3 isn’t a U.S. citizen or U.S. national, does PERSON 3 have eligible immigration status? Yes No
IfYES,llinPERSON3’sdocumenttypeandIDnumberbelow.
a. Immigrationdocumenttype: b. DocumentIDnumber:
c. HasPERSON3livedintheU.S.since1996? Yes No
d. IsPERSON3,theirspouseorparentaveteranoranactive-dutymemberoftheU.S.military? Yes No
16. IfyouhavenotappliedforaSocialSecurityNumber,listthereasons
Issuedfornon-workreasonsonly  NoSSNduetoreligiousreasons
No te lig ibl ef or SSN
Newborn,mothercurrentlyreceivingMedicaid Newborn,motherNOTreceivingMedicaid
17. DoesPERSON3wanthelppayingformedicalbillsfromthelast3months? Yes No
18. DoesPERSON3livewithatleastonechildunder19,andisPERSON2themainpersontakingcareofthischild? Yes No
19. IsPERSON3afull-timestudent? Yes No
20. WasPERSON3infostercareinSouthCarolinaatage18orolder? Yes No
21. IsPERSON3currentlylivinginafosterhome? Yes No
22. IsPERSON3currentlylivinginaDJJgrouphome? Yes No
Now, tell us about any income from PERSON 3 on the next page.
a. Ifyoudon’thaveaSSN,have
youappliedforone?
Yes
No
If no, indicate the reason at
question 16.
We need this if PERSON 3 wants health
coverage and has an SSN.
b. Wasthisperson’shouseholdincomethesameduringthese3monthsasitisnow?
Yes No
IfNO,enterthetotalmonthlyincomefor:LastMonth:$ 2
MonthsAgo:$ 3 MonthsAgo:$
a. IfYES,wasthisperson’shouseholdsizethesameduringthese3monthsasitisnow?
Yes No
NEED HELP WITH YOUR APPLICATION? Visit SCDHHS.gov or call us at 1-888-549-0820. Para obtener una copia de este formulario
en Español, llame 1-888-549-0820. If you need help in a language other than English, call 1-888-549-0820 and tell the customer service
representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-888-842-3620.
DHHS Form 3400 (Aug. 2020)
Page 9 of 13
Application for Medicaid and Aordable Health Coverage
STEP 1: PERSON 3
Current job & income information
Employed
Ifyou’recurrentlyemployed,tellusabout
yourincome.Startwithquestion25.
Not Employed
SKIPtoquestion37.
Self-Employed
SKIPtoquestion36.
CURRENT JOB 1:
25. Employernameandaddress 26. Employerphonenumber
27. Wages/tips(beforetaxes)
Hourly Weekly Every2weeks Twiceamonth Monthly Yearly
$ 28. Averagehoursworkedeachweek 29. Startdate
CURRENT JOB 2:(Ifyouhavemorejobsandneedmorespace,attachanothersheetofpaper)
30. Employernameandaddress 31. Employerphonenumber
32. Wages/tips(beforetaxes)
Hourly Weekly Every2weeks Twiceamonth Monthly Yearly
$ 33. Averagehoursworkedeachweek 34. Startdate
35. In the past year, did you: Changejobs Stopworking Startworkingfewerhours Noneofthese
36. If self-employed, answer the following questions:
a. Typeofwork b.Howmuchnetincome(protsoncebusinessexpensesarepaid
willyougetfromthisself-employmentthismonth?)
$
37. OTHER INCOME THIS MONTH:Checkallthatapply,andgivetheamountandhowoftenyougetit.
NOTE: Youdon’tneedtotellusaboutchildsupport,veteran’spaymentsorSupplementalSecurityIncome(SSI).
None
Unemployment $ Howoften? Netfarming/shing: $ Howoften?
Pensions $ Howoften? Netrental/royalty: $ Howoften?
SocialSecurity $ Howoften? Otherincome:
Retirementacc’ts$ Howoften? Type: $ Howoften?
Alimonyreceived$ Howoften?
Type: $ Howoften?
38. DEDUCTIONS: Checkallthatapply,andgivetheamountandhowoftenyougetit.
IfPERSON3paysforcertainthingsthatcanbedeductedonafederalincometaxreturn,tellingusaboutthemcouldmakethecostofhealth
coveragealittlelower.
NOTE: Youshouldn’tincludeacostthatyoualreadyconsideredinyouranswertonetself-employment.
Alimonypaid $ Howoften?
Otherdeductions: $ Howoften?
Studentloaninterest $ Howoften? Type:
39. YEARLY INCOME: Complete only if PERSON 3’s income changes from month to month.
If you don’t expect changes to PERSON 3’s monthly income, add another person on the following pages.
PERSON3’stotalincomethisyear PERSON3’stotalincomenextyear(ifyouthinkitwillbedierent)
$ $
24. Race (OPTIONAL—check all that apply)
White
AmericanIndianorAlaskanative
Vietnamese
Filipino
Black/AfricanAmerican
GuamanianorChamorro
Japanese AsianIndian
Samoan
OtherAsianChinese
Korean
OtherPacicIslander
Other:
NativeHawaiian
Mexican Mexican-American Chicano/a PuertoRican
Cuban Other:
23. If Hispanic/Latino, ethnicity (OPTIONAL)
NEED HELP WITH YOUR APPLICATION? Visit SCDHHS.gov or call us at 1-888-549-0820. Para obtener una copia de este formulario
en Español, llame 1-888-549-0820. If you need help in a language other than English, call 1-888-549-0820 and tell the customer service
representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-888-842-3620.
DHHS Form 3400 (Aug. 2020)
Page 10 of 13
Application for Medicaid and Aordable Health Coverage
STEP 1: PERSON 4
CompleteStep1foryourspouse/partnerandchildrenwholivewithyouand/oranyoneonyoursamefederalincometaxreturn
ifyouleone.Seepage2formoreinformationaboutwhomtoinclude.Ifyoudon’tleataxreturn,remembertostilladdfamily
memberswholivewithyou.
1. Firstname,Middlename,Lastname,&Sux 2. Relationshiptoyou?
3. Dateofbirth(mm/dd/yyyy) 4. Sex: Male Female 5. SocialSecuritynumber(SSN)
6. DoesPERSON4liveatthesameaddressasyou? Yes No
Ifno,listaddress:
7. Does Person 4 plan to le a federal income tax return NEXT YEAR?
(Youcanstillapplyforhealthinsuranceevenifyoudon’tleafederalincometaxreturn.)
YES.Ifyes,pleaseanswerquestionsa–c. NO.Ifno,SKIPtoquestionc.
a. WillPerson4lejointlywithaspouse? Yes NoIfyes,nameofspouse:
b. WillPerson4claimanydependentsonyourtaxreturn? Yes No
Ifyes,listdependents:
c. WillPerson4beclaimedasadependentonsomeone’staxreturn? Yes No
Ifyes,pleaselistthetaxler: Howareyourelatedtothetaxler?
8. Areyoupregnantorrecentlypregnant? Yes NoIfyes,a.Howmanybabiesareexpected? b. Whatisyourduedate?
c. Ifrecentlypregnant,enterthedatethepregnancyended:
d. WereyouenrolledinMedicaidonthelastdayofpregnancy? Yes No
9. Does PERSON 4 need health coverage? (Even if you have insurance, there might be a program with better coverage or lower costs)
YES.Ifyes,answerthequestionsbelow. NO.Ifno,SKIPtotheincomequestions.Leavetherestofthispageblank.
10. Doyouhaveadisablingphysical,mental,oremotionalhealthconditionthatcauseslimitationsinactivities? Yes No
11. Doyouneedtoliveinamedicalfacilityornursinghomeorneednursingservicesathome? Yes No
12. Haveyoubeendiagnosedwithandarereceivingtreatmentforanyofthefollowing? Yes No
•BreastCancer •CervicalCancer •AtypicalBreastHyperplasia •PrecancerousCervicalLesion(CIN2/3)
13. DoesPERSON4wanttoapplyforFamilyPlanningbenets? Yes No
Family Planning is a limited benet program, which provides family planning services, family planning-related services and certain limited
preventative screenings. Family Planning is not full Medicaid coverage. If you leave this question blank, we will not assess you for Family Planning.
14.a.IsPERSON4aU.S.citizen?(BorninU.S.;childofU.S.citizen;orformeraliennownaturalizedasaU.S.citizen)
Yes No
b. IsPERSON4aU.S.national?(BorninunincorporatedU.S.Territorywhoelectstobeanational,notaU.S.citizen) Yes No
15. If PERSON 4 isn’t a U.S. citizen or U.S. national, does PERSON 4 have eligible immigration status? Yes No
IfYES,llinPERSON4’sdocumenttypeandIDnumberbelow.
a. Immigrationdocumenttype: b. DocumentIDnumber:
c. HasPERSON4livedintheU.S.since1996? Yes No
d. IsPERSON4,theirspouseorparentaveteranoranactive-dutymemberoftheU.S.military? Yes No
16. IfyouhavenotappliedforaSocialSecurityNumber,listthereasons
Issuedfornon-workreasonsonly  NoSSNduetoreligiousreasons
No te lig ibl ef or SSN
Newborn,mothercurrentlyreceivingMedicaid Newborn,motherNOTreceivingMedicaid
17. DoesPERSON4wanthelppayingformedicalbillsfromthelast3months? Yes No
18. DoesPERSON4livewithatleastonechildunder19,andisPERSON4themainpersontakingcareofthischild? Yes No
19. IsPERSON4afull-timestudent? Yes No
20. WasPERSON4infostercareinSouthCarolinaatage18orolder? Yes No
21. IsPERSON4currentlylivinginafosterhome? Yes No
22. IsPERSON4currentlylivinginaDJJgrouphome? Yes No
We need this if PERSON 4 wants health
coverage and has an SSN.
Now, tell us about any income from PERSON 4 on the next page.
a. Ifyoudon’thaveaSSN,have
youappliedforone?
Yes
No
If no, indicate the reason at
question 16.
b. Wasthisperson’shouseholdincomethesameduringthese3monthsasitisnow?
Yes No
IfNO,enterthetotalmonthlyincomefor:LastMonth:$ 2
MonthsAgo:$ 3 MonthsAgo:$
a.
IfYES,wasthisperson’shouseholdsizethesameduringthese3monthsasitisnow?
Yes No
NEED HELP WITH YOUR APPLICATION? Visit SCDHHS.gov or call us at 1-888-549-0820. Para obtener una copia de este formulario
en Español, llame 1-888-549-0820. If you need help in a language other than English, call 1-888-549-0820 and tell the customer service
representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-888-842-3620.
DHHS Form 3400 (Aug. 2020)
Page 11 of 13
Application for Medicaid and Aordable Health Coverage
STEP 1: PERSON 4
Current job & income information
Employed
Ifyou’recurrentlyemployed,tellusabout
yourincome.Startwithquestion25.
Not Employed
SKIPtoquestion37.
Self-Employed
SKIPtoquestion36.
CURRENT JOB 1:
25. Employernameandaddress 26. Employerphonenumber
27. Wages/tips(beforetaxes)
Hourly Weekly Every2weeks Twiceamonth Monthly Yearly
$ 28. Averagehoursworkedeachweek 29. Startdate
CURRENT JOB 2:(Ifyouhavemorejobsandneedmorespace,attachanothersheetofpaper)
30. Employernameandaddress 31. Employerphonenumber
32. Wages/tips(beforetaxes)
Hourly Weekly Every2weeks Twiceamonth Monthly Yearly
$ 33. Averagehoursworkedeachweek 34. Startdate
35. In the past year, did you: Changejobs Stopworking Startworkingfewerhours Noneofthese
36. If self-employed, answer the following questions:
a. Typeofwork b.Howmuchnetincome(protsoncebusinessexpensesarepaid
willyougetfromthisself-employmentthismonth?)
$
37. OTHER INCOME THIS MONTH:Checkallthatapply,andgivetheamountandhowoftenyougetit.
NOTE: Youdon’tneedtotellusaboutchildsupport,veteran’spaymentsorSupplementalSecurityIncome(SSI).
None
Unemployment $ Howoften? Netfarming/shing: $ Howoften?
Pensions $ Howoften? Netrental/royalty: $ Howoften?
SocialSecurity $ Howoften? Otherincome:
Retirementacc’ts$ Howoften? Type: $ Howoften?
Alimonyreceived$ Howoften?
Type: $ Howoften?
38. DEDUCTIONS: Checkallthatapply,andgivetheamountandhowoftenyougetit.
IfPERSON4paysforcertainthingsthatcanbedeductedonafederalincometaxreturn,tellingusaboutthemcouldmakethecostofhealth
coveragealittlelower.
NOTE: Youshouldn’tincludeacostthatyoualreadyconsideredinyouranswertonetself-employment.
Alimonypaid $ Howoften?
Otherdeductions: $ Howoften?
Studentloaninterest $ Howoften? Type:
39. YEARLY INCOME: Complete only if PERSON 4’s income changes from month to month.
If you don’t expect changes to PERSON 4’s monthly income, add another person on the following pages.
PERSON4’stotalincomethisyear PERSON4’stotalincomenextyear(ifyouthinkitwillbedierent)
$ $
24. Race (OPTIONAL—check all that apply)
White
AmericanIndianorAlaskanative
Vietnamese
Filipino
Black/AfricanAmerican
GuamanianorChamorro
Japanese AsianIndian
Samoan
OtherAsianChinese
Korean
OtherPacicIslander
Other:
NativeHawaiian
Mexican Mexican-American Chicano/a PuertoRican
Cuban Other:
23. If Hispanic/Latino, ethnicity (OPTIONAL)
NEED HELP WITH YOUR APPLICATION? Visit SCDHHS.gov or call us at 1-888-549-0820. Para obtener una copia de este formulario
en Español, llame 1-888-549-0820. If you need help in a language other than English, call 1-888-549-0820 and tell the customer service
representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-888-842-3620.
DHHS Form 3400 (Aug. 2020)
Page 12 of 13
Application for Medicaid and Aordable Health Coverage
STEP 2
American Indian or Alaska Native (AI/AN) family member(s)
1. AreyouorisanyoneinyourfamilyAmericanIndianorAlaskaNative?
If NO, skiptoStep3.
YES. If YES, askforandcompleteSCDHHSForm3400-AppendixB(AmericanIndianorAlaskaNativeFamilyMember).
STEP 3
Your family’s health coverage
Answerthesequestionsforanyonewhoneedshealthcoverage.
1. Is anyone enrolled in health coverage now from the following? Ifavailable,pleaseprovideacopyoftheinsurancecard.
YES.Ifyes,checkthetypeofcoverageandwritetheperson(s)’name(s)nexttothecoveragetheyhave. NO.
Medicaid Employerinsurance
CHIP Nameofhealthinsurance:
Medicare Policynumber: StartDate:
Claimnumber: IsthisCOBRAcoverage? Yes No
DateMedicarecoveragestarted: Isthisaretireehealthplan? Yes No
TRICARE(Don’tcheckifyouhavedirectcareofLineOfDuty) Otherhealthinsurance
Nameofhealthinsurance:
VAhealthcareprograms: Policynumber: StartDate:
PeaceCorps: Isthisalimited-timebenetplan(ex:aschoolaccidentpolicy)? Y N
2. Is anyone listed on this application oered health coverage from a job? Checkyesevenifthecoverageisfromsomeoneelse’sjob,such
asaparentorspouse.
YES. If YES,you’llneedtocompleteandincludeAppendixA.Isthisastateemployeebenetplan? Yes No
NO. If NO,continuetoStep4.
STEP 4
1. Iknowthatunderfederallaw,discriminationisn’tpermittedonthebasisofrace,color,nationalorigin,sex,age,ordisability.
Icanleacomplaintofdiscriminationbycalling(888)808-4238orwritingtotheCivilRightsDivision,SCDHHS,P.O.Box8206,
Columbia,SC29202-8206.
2. IknowIwillbeaskedtocooperatewiththeagencythatcollectsmedicalsupportfromanabsentparent.IfIthinkthat
cooperatingtocollectmedicalsupportwillharmmeormychildren,Icantelltheagencyandmaynothavetocooperate.
Read and Sign.Pleasereadthefollowingrightsandresponsibilities.Ifyoudisagreewithastatement,
youreligibilityforprogramsmaybeimpacted.Asignatureisrequiredtocompletetheapplication
processandsubmityourapplicationtotheagency.
3. IassignandgivemyrightstoanypaymentsfromaliablethirdpartytotheSCDHHSuptothepaymentamountthatHealthy
Connectionshasmadeformymedicalcare.Thisassignmentappliestoanyofmyminorchildrenwhomaybeinjured.These
paymentsmayincludepaymentsfromhealthinsurance,legalsettlements,orotherthirdparties.IalsounderstandthatIhave
adutytocooperateinidentifyingandprovidinginformationtoassistHealthyConnectionsinpursuingthirdpartieswhomay
beliabletopayforcareandservices.
4. IunderstandthatImustcooperatefullywithstateandfederalworkersifmycaseisreviewed.Ialsounderstandthat,asa
conditionofeligibility,Imustapplyforandtakestepstoobtainanyotherbenets,includingbutnotlimitedtoannuities,
pensions,retirement,disabilityandotherbenets.
5. Asanapplicant/beneciaryforMedicaidservices,Iunderstandthattherearetwogroupsofpeoplethatareaectedby
estaterecovery:
• Apersonofanyagewhowasapatientinanursingfacility,intermediatecarefacilityfortheintellectuallydisabled,orother
medicalinstitutionatthetimeofdeath,andwhowasrequiredtopaymostofhis/herincomeforthecostofcare;or
• Apersonwhowas55yearsofageorolderwhenhe/shereceivedmedicalassistanceconsistingofnursingfacility
services,homeandcommunitybasedservices,andhospitalandprescriptiondrugservicesprovidedtoindividualsin
nursingfacilitiesorreceivinghomecommunity-basedservices.
Iunderstandthatuponreceivinganyoftheseservices,theDepartmentofHealthandHumanServiceswillleaclaim
againstmyestate(allpersonalandrealpropertyownedbymeatmydeath)fortheamountMedicaidhaspaidformy
services.
NEED HELP WITH YOUR APPLICATION? Visit SCDHHS.gov or call us at 1-888-549-0820. Para obtener una copia de este formulario
en Español, llame 1-888-549-0820. If you need help in a language other than English, call 1-888-549-0820 and tell the customer service
representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-888-842-3620.
DHHS Form 3400 (Aug. 2020)
Page 13 of 13
Application for Medicaid and Aordable Health Coverage
6. IknowthatImusttellSCDHHSwithin10daysifanyinformationIlistedonthisapplicationchangesandisdierentthan
whatIwroteonthisapplication.Iunderstandthatachangeinmyinformationcouldaecttheeligibilityformember(s)ofmy
household.
7. TheinformationIprovideonthisapplicationandinfutureinteractionwithSCDHHSwillbeusedtocheckmyeligibilityfor
helppayingforhealthcoverage,ifIchoosetoapply.IftheinformationIprovidedoesn’tmatchelectronicdata,Imaybe
askedtosendproof.Iknowthat,unlessIspecicallyasktobeexcluded,informationcollectedwillbesecurelystoredin
ordertobesurethatservicesprovidedtomyfamilyandmearesucientandnecessary.
8. IfIthinkSCDHHS,theagencythatadministersHealthyConnections,thestate’sMedicaidprogram,hasmadeanerrorIcan
appealitsdecision.ToappealmeanstotellsomeoneatSCDHHSthatIthinktheactioniswrong,andaskforafairhearing.
ImustsubmitawrittenrequestforsuchahearingtoSCDHHS.IknowthatImayrepresentmyselforberepresentedby
someoneotherthanmyself.
9. IknowthatpersonalhealthinformationIprovideorthatislatergatheredbySCDHHSiscoveredbytheHealthInsurance
PortabilityandAccountabilityActof1996(HIPAA)andIwillreceiveaNoticeofPrivacyPracticesalongwithmyHealthy
ConnectionsCard(s).
Doesanychildonthisapplicationhaveaparentlivingoutsideofthehome?
Yes No
Iconrmthatnooneapplyingforhealthinsuranceonthisapplicationisincarcerated(detainedorjailed).Ifnot,
isincarcerated.
Renewal of coverage in future years
Tomakeiteasiertodeterminemyeligibilityforhelppayingforhealthcoverageinfutureyears,IagreetoallowMedicaidorthe
HealthInsuranceMarketplacetouseincomedata,includinginformationfromtaxreturns.Medicaidwillsendmeanotice,let
memakeanychanges,andIcanoptoutatanytime.
Yes,renewmyeligibilityautomaticallyforthenext:
5years(themaximumnumberofyearsallowed),orforashorternumberofyears:
4years 3years 2years 1year Don’tuseinformationfromtaxreturnstorenewmycoverage.
Sign this application. ThepersonwholledoutStep1shouldsignthisapplication.Ifyou’reanauthorizedrepresentative,you
maysignhere,aslongasyouhaveprovidedtheinformationrequiredonDHHSForm1282-AuthorizedRepresentative.
Bysigning,IstatethatIhavereadandagreetotherightsandresponsibilitiesstatedonthisapplication.Iamsigningthis
applicationunderpenaltyofperjury.ThismeansIhaveprovidedtrueanswerstoallthequestionsonthisformtothebestofmy
knowledge.IknowthatifIamnottruthful,theremaybeapenaltyunderfederallaw.
Signature Date(mm/dd/yyyy)
Pleaseprintthisform,thensignitonthelineabovebeforesubmitting.
STEP 5
Mail the completed application.
Mailyoursignedapplicationto:
Ifyouwanttoregistertovote,you
cancompleteavoterregistration
formatscvotes.org.
SCDHHS - Central Mail
PO Box 100101
Columbia SC 29202-3101
NEED HELP WITH YOUR APPLICATION? Visit SCDHHS.gov or call us at 1-888-549-0820. Para obtener una copia de este formulario
en Español, llame 1-888-549-0820. If you need help in a language other than English, call 1-888-549-0820 and tell the customer service
representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-888-842-3620.
DHHS Form 3400 - Appendix A (January 2014)DW Page 1 of 2
EMPLOYEE information
1.Employeename(First,Middle,Last) 2.EmployeeSocialSecuritynumber
EMPLOYER information
3.Employername 4.EmployerIdenticationNumber(EIN)
5.Employeraddress 6.Employerphonenumber
7.City 8.State 9.ZIPcode
10.Whocanwecontactaboutemployeehealthcoverageatthisjob?
11.Phonenumber(ifdierentfromabove) 12.Emailaddress
13.Are you currently eligible for coverage oered by this employer, or will you become eligible in the next 3 months?
YES.IfYES,continuebelow. NO.IfNO,stophereandgotoStep3ontheapplication.
13a.Ifyou’reinawaitingorprobationaryperiod,whencanyouenrollincoverage?
(mm/dd/yyyy)
Listthenamesofanyoneelsewhoiseligibleforcoveragefromthisjob.
Name: Name: Name:
Tellusaboutthehealth planoeredbythisemployer.
14.Doestheemployeroerahealthplanthatmeetstheminimumvaluestandard*? Yes No
15.Forthelowest-costplanthatmeetstheminimumvaluestandard*oeredonlytotheemployee(don’tincludefamilyplans):Iftheemployer
haswellnessprograms,providethepremiumthattheemployeewouldpayifhe/shereceivedthemaximumdiscountforanytobaccocessa-
tionprograms,anddidnotreceiveanyotherdiscountsbasedonwellnessprograms.
a.Howmuchwouldtheemployeehavetopayinpremiumsforthisplan?$
b.Howoften? Weekly Every2weeks Twiceamonth Monthly Yearly
16.Whatchangewilltheemployermakeforthenewplanyear(ifknown)?
Employerwon’toerhealthcoverage
Employerwillstartoeringhealthcoveragetoemployeesorchangethepremiumforthelowest-costplanavailableonlytotheemployee
thatmeetstheminimumvaluestandard.*(Premiumshouldreectthediscountforwellnessprograms.Seequestion15.)
a.Howmuchwouldtheemployeehavetopayinpremiumsforthisplan?$
b.Howoften? Weekly Every2weeks Twiceamonth Monthly Yearly
Dateofchange(mm/dd/yyyy):
*Anemployer-sponsoredhealthplanmeetsthe“minimumvaluestandard”iftheplan’sshareofthetotalallowedbenetcostscoveredbythe
planisnolessthan60percentofsuchcosts[Section36B(c)(2)(C)(ii)oftheInternalRevenueCodeof1986]
APPENDIX A
Health Coverage from Jobs
YouDON’Tneedtoanswerthesequestionsunlesssomeoneinthehouseholdiseligibleforhealthcoveragefromajob.Attachacopyofthis
pageforeachjobthatoerscoverage.
Tell us about the job that oers coverage.
Take the Employer Coverage Tool on the next page to the employer who oers coverage to help you answer these questions. You only need
to include this page when you send in your application, not the Employer Coverage Tool.
( )
( )
NEED HELP WITH YOUR APPLICATION? Visit SCDHHS.gov or call us at 1-888-549-0820. Para obtener una copia de este formulario
en Español, llame 1-888-549-0820. If you need help in a language other than English, call 1-888-549-0820 and tell the customer service
representative the language you need. We’ll get you help at no cost to you. TTY users should call 1-888-842-3620.
DHHS Form 3400 - Appendix A (January 2014)DW Page 2 of 2
EMPLOYER COVERAGE TOOL
Health Coverage from Jobs
UsethistooltohelpanswerquestionsinAppendixAaboutanyemployerhealthcoveragethatyou’reeligiblefor(evenifit’sfromanother
person’sjob,likeaparentorspouse).TheinformationinthenumberedboxesbelowmatchtheboxesonAppendixA.Forexample,theanswer
toquestion14onthispageshouldmatchquestion14onAppendixA.
WriteyournameandSocialSecuritynumberinboxes1and2andasktheemployertollouttherestoftheform.
Completeonetoolforeachemployerthatoershealthcoverage.
EMPLOYEE Information
Theemployeeneedstolloutthissection.
1.Employeename(First,Middle,Last) 2.EmployeeSocialSecuritynumber
EMPLOYER Information
Theemployerneedstolloutthissection.
3.Employername 4.EmployerIdenticationNumber(EIN)
5.Employeraddress 6.Employerphonenumber
7.City 8.State 9.ZIPcode
10.Whocanwecontactaboutemployeehealthcoverageatthisjob?
11.Phonenumber(ifdierentfromabove) 12.Emailaddress
13.Is the employee currently eligible for coverage oered by this employer, or will the employee become eligible in the next 3 months?
YES.IfYES,continuebelow. NO.IfNO,stophereandgotoStep3ontheapplication.
13a.Iftheemployeeisnoteligibletoday,includingasaresultofawaitingorprobationaryperiod,whenistheemployeeeligiblefor
coverage?
 (mm/dd/yyyy)
Listthenamesofanyoneelsewhoiseligibleforcoveragefromthisjob.
Name: Name: Name:
Tellusaboutthehealth planoeredbythisemployer.
14.Doestheemployeroerahealthplanthatmeetstheminimumvaluestandard*? Yes No
15.Forthelowest-costplanthatmeetstheminimumvaluestandard*oeredonlytotheemployee(don’tincludefamilyplans):Iftheemployer
haswellnessprograms,providethepremiumthattheemployeewouldpayifhe/shereceivedthemaximumdiscountforanytobaccocessa-
tionprograms,anddidnotreceiveanyotherdiscountsbasedonwellnessprograms.
a.Howmuchwouldtheemployeehavetopayinpremiumsforthisplan?$
b.Howoften? Weekly Every2weeks Twiceamonth Monthly Yearly
16.Whatchangewilltheemployermakeforthenewplanyear(ifknown)?
Employerwon’toerhealthcoverage
Employerwillstartoeringhealthcoveragetoemployeesorchangethepremiumforthelowest-costplanavailableonlytotheemployee
thatmeetstheminimumvaluestandard.*(Premiumshouldreectthediscountforwellnessprograms.Seequestion15.)
a.Howmuchwouldtheemployeehavetopayinpremiumsforthisplan?$
b.Howoften? Weekly Every2weeks Twiceamonth Monthly Yearly
Dateofchange(mm/dd/yyyy):
*Anemployer-sponsoredhealthplanmeetsthe“minimumvaluestandard”iftheplan’sshareofthetotalallowedbenetcostscoveredbythe
planisnolessthan60percentofsuchcosts[Section36B(c)(2)(C)(ii)oftheInternalRevenueCodeof1986]
( )
( )
NEED HELP WITH YOUR APPLICATION? Visit SCDHHS.govorcallusat1-888-549-0820.Paraobtenerunacopiadeesteformulario
enEspañol,llame1-888-549-0820.IfyouneedhelpinalanguageotherthanEnglish,call1-888-549-0820andtellthecustomerservice
representativethelanguageyouneed.We’llgetyouhelpatnocosttoyou.TTYusersshouldcall1-888-842-3620.
DHHSForm1282-AuthorizedRepresentative(October2015) Page 1 of 1MemberVerication
Medicaidapplicant/member’ssignature Date(mm/dd/yyyy)
Ifsigningwithan“X,”pleasehavetwopeoplesignbelowaswitnesses.
Witness: Witness:
Memberisincapacitatedandunabletosign.SCDHHSreservestherighttoverifymember’sinabilitytosign.Providereason:
Authorization for Release of Information and
Appointment of Authorized Representative
for Medicaid Applications/Reviews and Appeals
NameofMedicaidapplicant/member SocialSecurityNumber
Appointing an Authorized Representative
Mail your signed form to:SCDHHS-CentralMail,POBox100101,Columbia,SC29202-3101 Fax:(888)820-1204
Is there anyone that you would like us to share information with about your application?
By completing thissection, youcan givepermission for thefollowing personto receiveinformation about yourapplication/
case,buttheywon’thavetheabilitytoactonyourbehalflikeanauthorizedrepresentative.YoualsogiveSCDHHSpermissionto
releaseinformationaboutthisapplicationtothisadditionalpersonororganization.
Nameofperson/organization Phone
Address City State ZIP
Unit(ifapplicable) IDNumber(ifapplicable)
OR
Permission to Release Information
NameofAuthorizedRepresentative(Firstname,Middlename,Lastname)
AuthorizedRepresentative’saddress(Leaveblankifyoudon’thaveone.)Apartmentorsuitenumber
CityStateZIPcode
AuthorizedRepresentative’sphonenumberOtherphonenumber
AuthorizedRepresentative’semailaddress
Organizationname(ifapplicable)Unit*(ifapplicable)IDnumber(ifapplicable)
New
Change
Addition
Removethispersonororganization
asmyauthorizedrepresentative
*Itisbesttoidentifyaspecicunitforlargeorganizations.
Would you like to allow someone to represent you on all matters related to your case?
Youcangiveatrustedpersonoranorganizationpermissiontotalkaboutyourapplicationwithus,seeyourinformation,andact
foryouonmattersrelatedtoyourapplication,includinggettinginformationaboutyourapplicationandsigningyourapplication
onyour behalf. Thispersoncan alsoact foryou on othermatters, includingreviews,appeals andmanaged careprocesses.
Thispersoniscalledan“authorizedrepresentative.”TheMedicaideligibilityworkercanreleaseanyinformationregardingyour
application/reviewandstatustoyourauthorizedrepresentativeoranymemberoftheorganizationindicatedonthisform.More
thanonepersonororganizationcanserveasyourauthorizedrepresentative.
Youcan appoint, withdrawor changean authorizedrepresentative atany time.If youever needto changeyour authorized
representative,contactHealthyConnections.Ifyouarealegallyappointedrepresentativeforsomeoneonthisapplication,you
donotneedtocompletethissection.
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Completed 25 January 2021

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