Outline
The Florida DH 3212 form is an essential document designed to facilitate access to extended family planning benefits under a special Medicaid program. This application is specifically tailored for individuals who have lost full Medicaid coverage and are seeking family planning services to help delay pregnancy. To initiate the process, applicants must provide personal information, including their name, contact details, and residence. The form also requires responses to several questions regarding reproductive history, such as whether the applicant has undergone a hysterectomy or tubal ligation, as well as their last menstrual period. Additionally, the form gathers information about household members, their income sources, and any existing health insurance coverage. It is crucial for applicants to attach proof of U.S. citizenship and identity, as well as to sign a certification that allows the Department of Health to access necessary confidential information. Understanding the requirements and completing the DH 3212 accurately can significantly impact eligibility for the Medicaid Family Planning Waiver program, which is aimed at individuals with specific income thresholds and family planning needs.
Sample - Florida Dh 3212 Form
DH 3212, 11/06 Stock No. 5744-000-3212-0
Health Insurance Application for Extended Family Planning Benefits
A Special Medicaid Program
Office Date Received
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
Applicant
**Social Security
Number
Date of Birth Race Sex US Citizen?
Yes No
** If no, give INS
ID Number
Date of
Entry
Applied for
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
Receiving Income
Income Source Gross Income
(Before Deduction)
How Often Are You Paid This Amount?
(weekly, biweekly, monthly)
Additional Information
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
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.
Form Information
| Fact Name | Details |
|---|---|
| Form Purpose | The Florida DH 3212 form is used to apply for extended family planning benefits under Medicaid. |
| Eligibility Criteria | Applicants must have lost full Medicaid, not have had a hysterectomy or tubal ligation, not be pregnant, desire family planning services, and have an income at or below 185% of the federal poverty level. |
| Required Information | Applicants must provide personal information, reproductive history, and details about household members and their income. |
| Proof of Citizenship | Only the applicant must submit proof of U.S. citizenship and identity, such as a U.S. passport or birth certificate. |
| Health Insurance Inquiry | Applicants are asked whether they have health insurance and if family planning is a covered benefit. |
| Signature Requirement | The applicant must sign and date the form to certify the information provided is accurate. |
| Submission Instructions | The completed form must be mailed or delivered to the local county health department, not Medicaid. |
| Confidentiality | The information provided will be kept confidential according to Florida and federal laws. |
| Governing Law | The form is governed by Florida Statutes related to Medicaid and family planning services. |
| Form Version | The current version of the form is dated November 2006. |
Detailed Guide for Filling Out Florida Dh 3212
Completing the Florida DH 3212 form is a crucial step in applying for extended family planning benefits through Medicaid. After filling out the form, you will need to submit it to your local county health department for processing. Ensure that all required information is accurately provided to avoid delays in your application.
- Begin by entering the Office Date Received at the top of the form.
- Fill in your Name (First, Middle Initial, Last) and Maiden Name.
- Provide your Area Code and Phone Number.
- Complete your Residence information, including Number, Street, Apt. No., City, County, State, and Zip Code.
- If your mailing address is different from your residence, fill in the Mailing Address section.
- If you do not have a home phone, provide a number where you can be reached.
- Answer the questions regarding your reproductive history (1-3) by marking Yes or No as applicable.
- List all individuals living in your home in question 4, starting with your name. Include their Relationship, Social Security Number, Date of Birth, Race, Sex, and whether they are a U.S. Citizen.
- For question 5, provide income information for everyone in your home who receives money. Include their Name, Income Source, Gross Income, and how often they are paid.
- Answer questions 6-8 regarding health insurance and KidCare enrollment.
- Attach proof of U.S. citizenship and identity, such as a U.S. Passport or Birth Certificate, to the application.
- Read the Certification and Authorization section carefully, then sign and date the form.
- Finally, mail or bring the completed application to your local county health department. Do not send it to Medicaid.
Obtain Answers on Florida Dh 3212
-
What is the purpose of the Florida DH 3212 form?
The Florida DH 3212 form is used to apply for the Health Insurance Application for Extended Family Planning Benefits, which is a special Medicaid program. This program aims to provide family planning services to eligible individuals who have lost their full Medicaid coverage. It helps individuals access necessary services to delay pregnancy and manage reproductive health effectively.
-
Who is eligible to apply for the Family Planning Waiver Program?
To be eligible for the Family Planning Waiver Program, applicants must meet specific criteria:
- They must have lost their full Medicaid benefits.
- They should not have undergone a hysterectomy or tubal ligation.
- Applicants must not be currently pregnant.
- They must express a desire for family planning services.
- Income should be less than or equal to 185% of the current federal poverty level.
Meeting these requirements is essential for successful application and approval.
-
What information do I need to provide on the form?
The form requires various personal details, including:
- Your name, contact information, and residence.
- Details about your reproductive health history, including any past surgeries.
- A list of individuals living in your household, including their relationships to you.
- Income information for everyone in your home, including sources and amounts.
- Health insurance details, if applicable.
Only the applicant needs to provide their Social Security Number and proof of U.S. citizenship and identity. This information is crucial for determining eligibility.
-
How do I submit the DH 3212 form?
Once you have completed the form, it should not be sent to Medicaid directly. Instead, you must mail or bring the application to your local county health department. It is important to ensure that all sections of the form are filled out accurately to avoid delays in processing your application.
Common mistakes
Filling out the Florida DH 3212 form can be a crucial step in securing family planning benefits. However, many people make common mistakes that can delay their application. One frequent error is not providing complete contact information. It’s essential to include both your residence and mailing addresses. If these differ, omitting the mailing address can lead to missed communications regarding your eligibility.
Another mistake involves answering the questions inaccurately or incompletely. For instance, when asked about previous medical procedures like a hysterectomy or tubal ligation, be sure to answer honestly. Misrepresenting your medical history can jeopardize your application. Additionally, many applicants forget to provide the date of their last menstrual period, which is a critical piece of information for determining eligibility.
Providing insufficient information about household members is another common pitfall. When listing everyone who lives in your home, ensure you include all required details, such as Social Security numbers and dates of birth. This information is vital for assessing household income and eligibility. Also, remember that only the applicant needs to provide proof of citizenship and identity, but this must be done correctly with certified copies or originals.
Income reporting can also be tricky. Applicants often fail to include all sources of income for everyone in the household. This includes child support, unemployment benefits, and any other financial contributions. Make sure to detail how often you receive this income, as this information plays a significant role in determining eligibility for the program.
Another mistake is neglecting to check the health insurance questions thoroughly. If you do have health insurance, you must provide the name of the insurance company. Forgetting to answer these questions can lead to unnecessary delays in processing your application.
Many applicants overlook the importance of signing and dating the form. The certification section confirms that you understand the information provided is accurate. Failing to sign can result in the application being returned or rejected.
Lastly, it’s crucial to remember where to send the application. Some people mistakenly send their forms to Medicaid instead of their local county health department. This misdirection can significantly delay the review process.
By avoiding these common mistakes, you can help ensure a smoother application process for the Florida DH 3212 form and increase your chances of receiving the benefits you need.
Documents used along the form
The Florida DH 3212 form is part of the application process for the Medicaid Family Planning Waiver Program. Several other forms and documents are often required or recommended to accompany this application. Below is a list of commonly used documents that may assist in the application process.
- Proof of U.S. Citizenship: This document verifies the applicant's citizenship status. Acceptable forms include a U.S. Passport, Birth Certificate, or other certified documents.
- Social Security Card: The applicant must provide their Social Security Number to establish identity and eligibility for benefits.
- Income Verification: Recent pay stubs or tax returns that demonstrate the applicant's income level are necessary to assess eligibility based on income guidelines.
- Medicaid Denial Letter: If applicable, a letter showing that the applicant has been denied full Medicaid benefits can support the application for the Family Planning Waiver.
- Child Support Documentation: If the applicant receives child support, documentation of the amount and frequency is required to include in the income assessment.
- Health Insurance Information: Details about any existing health insurance coverage, including the name of the insurance company, are needed to evaluate available benefits.
- Proof of Residency: Documents such as utility bills or rental agreements can confirm the applicant's current residence, which is essential for eligibility determination.
- Application for KidCare Program: If the applicant is under 18, they may need to provide documentation related to their enrollment in the KidCare program.
- Authorization for Release of Information: This form allows the Department of Health to obtain necessary medical and financial information to process the application.
- Additional Family Member Information: For applications involving multiple household members, documentation of their income and citizenship may also be necessary.
Gathering these documents can streamline the application process for the Florida DH 3212 form. Proper documentation ensures that eligibility is assessed accurately and efficiently, reducing potential delays in receiving benefits.
Similar forms
- Florida DH 3200 Form: Similar to the DH 3212, this form also serves as an application for Medicaid benefits, focusing on eligibility and personal information. Both require details about household income and insurance coverage.
- Florida DH 3201 Form: This document is used for applying for Medicaid for children. Like the DH 3212, it collects personal information and income details but is specifically tailored for minors and their families.
- Florida DH 3202 Form: This form is for pregnant women seeking Medicaid. It shares similarities with the DH 3212 in that it assesses eligibility based on income and provides access to healthcare services, though it focuses on prenatal care.
- Florida DH 3203 Form: Designed for individuals applying for long-term care Medicaid, this form requires similar information regarding income and residency. It aims to determine eligibility for extended healthcare services.
- Florida DH 3204 Form: This document is for individuals applying for the Medicaid Aged and Disabled program. It parallels the DH 3212 in its focus on income and living arrangements, catering specifically to older adults and disabled individuals.
- Florida DH 3205 Form: This form is used for the Medicaid Spend Down program. It is similar to the DH 3212 in that it assesses financial eligibility, helping individuals with high medical expenses qualify for Medicaid assistance.
Dos and Don'ts
When filling out the Florida DH 3212 form, there are several important guidelines to follow. Below is a list of things you should and shouldn't do.
- Do ensure all personal information is accurate and complete.
- Do provide your Social Security Number and proof of citizenship as the applicant.
- Do answer all questions honestly, particularly those regarding your reproductive history.
- Do include your mailing address if it differs from your residence address.
- Don't forget to sign and date the form after losing full Medicaid coverage.
- Don't leave any sections blank; incomplete applications can delay processing.
- Don't send the application to Medicaid; instead, submit it to your local county health department.
Misconceptions
Misconceptions about the Florida DH 3212 form can lead to confusion and delays in receiving benefits. Here are seven common misconceptions, along with clarifications:
- Only the applicant needs to provide information. Many believe that only the applicant's details are necessary. However, information about all household members is required, including their income and relationship to the applicant.
- Proof of citizenship can be submitted in any format. Some think any document will suffice as proof of citizenship. In reality, only original or certified copies of specific documents, such as a U.S. Passport or Birth Certificate, are acceptable.
- The application can be submitted online. There is a misconception that the DH 3212 form can be submitted electronically. Instead, applicants must mail or bring the application to their local county health department.
- Income from all sources is not important. Some applicants may think that only employment income matters. However, all income sources, including child support and unemployment benefits, must be reported.
- The application process is quick and easy. Many individuals underestimate the time required to complete the application accurately. Incomplete forms can lead to delays in determining eligibility.
- Health insurance is not relevant to the application. Some believe that having health insurance disqualifies them from applying. In fact, the application asks about existing health insurance to assess eligibility for family planning services.
- Signing the form is just a formality. Many applicants think that signing the certification section is unimportant. However, this signature is crucial as it authorizes the release of confidential information necessary for eligibility determination.
Understanding these misconceptions can help streamline the application process and ensure that applicants receive the benefits they need in a timely manner.
Key takeaways
Filling out the Florida DH 3212 form is an important step for those seeking extended family planning benefits through Medicaid. Here are some key takeaways to help you navigate the process:
- Eligibility Criteria: You may qualify for the Medicaid Family Planning Waiver program if you have lost full Medicaid, have not undergone a hysterectomy or tubal ligation, are not currently pregnant, desire family planning services, and have an income at or below 185% of the federal poverty level.
- Complete All Sections: Ensure that you fill out all sections of the application, including personal information, reproductive history, and household income. Incomplete forms can delay your eligibility determination.
- Provide Accurate Information: When listing household members, include yourself first and provide accurate details such as Social Security numbers and proof of citizenship only for the applicant.
- Income Reporting: Include all sources of income for everyone living in your home, not just your own. This includes wages, child support, and any other financial support received.
- Health Insurance Details: If you have health insurance, indicate this on the form and provide the name of your insurance company. This information is crucial for assessing your eligibility for family planning benefits.
- Documentation Required: Attach proof of U.S. citizenship and identity, such as a U.S. passport or birth certificate. Only original or certified copies will be accepted.
- Certification and Authorization: Sign and date the form to certify that the information provided is true. This authorization allows the Department of Health to access necessary information for eligibility determination.
- Submission Instructions: Do not send the application to Medicaid. Instead, mail or bring it to your local county health department for processing.
- Follow-Up: After submitting your application, be prepared to respond to any requests for additional information, which may come via phone or mail.
Understanding these key points can streamline your application process and help ensure you receive the benefits you need. Take your time to gather the required information and complete the form accurately.