5005-2        THE APPLICATION FORM

5005-2 A.   What is an Acceptable Application Form?

The Gen 50B, Application for Services form, is the initial application form that is used to apply for any public assistance program, except the Heating Assistance Program.  To apply for Heating Assistance, a Heating Assistance Program application must be completed.

The Gen 72, Eligibility Review Form, is the review application form that is used to determine continued eligibility for Adult Public Assistance, Food Stamps, Medicaid, and Temporary Assistance.  

• If received in the month following case closure for any reason, the Gen 72 Eligibility Review Form form can be used as an initial application form.
   

• If received after the month following the end of the review period, a Gen 50B application form is required.  The Gen 72 form will be accepted to protect the benefit start date; however, it cannot be used as the initial application form.

The Native Family Assistance Program (NFAP) TANF application form is an acceptable application form for Adult Public Assistance, Food Stamps, Medicaid, and Temporary Assistance.

The following specialized application forms are also available and their use is encouraged when appropriate:

The Gen 132, Denali KidCare Application, used for all poverty level children, pregnant women, and all children applying for or receiving SSI Supplemental Security Income;

The Gen 33, Application for Medicaid and Title IV-E Foster Care for a child in DHSS Custody, used by the Office of Children’s Services (OCS) to apply for children in state custody, Title IV-E foster care and adoption assistance agreements, and state-only adoption assistance agreements;

The Gen 35, Application for Medicaid for a child in DHSS Department of Health and Social Services (State) Custody, used by youth corrections staff and specialized/Title IV-E caseworkers.

5005-2 B.   When is an Application Required?

1. Upon the individual's first application for a program, except if the individual is already a recipient of another DPA assistance program.
    

2. Upon application from a denied, withdrawn, or closed status, unless the denial or closure was the result of an administrative error.
    

3. Any time the caseworker believes the individual’s circumstances have changed sufficiently to justify conducting a special redetermination of eligibility, including when an office conducts a special review project for all or part of its caseload.

4. The department does not have enough information to determine eligibility. If an individual is receiving Denali KidCare and does not have any other active public assistance cases, a new application is necessary to determine eligibility for another Medicaid category, such as Family Medicaid.

Example:

A woman has been receiving Denali KidCare pregnancy Medicaid but her post-partum coverage is ending 4/30/10. She requests Family Medicaid coverage for herself on 4/5/10 and she does not have any other active public assistance cases. The department does not have enough information to determine eligibility, so a new application is required.

5005-2 C.   When is an Application Not Required?

1. To reopen a closed case as a result of an individual's timely request for a fair hearing, or to open or reopen a case as the result of a fair hearing decision.
    

2. To reopen a case that had been closed incorrectly.
    

3. To redetermine eligibility after the initial application is denied for failing to provide verification and the household provides the verification within 30 days from the application filing date.
    

4. To redetermine eligibility after the application is denied for failing to attend an interview and the household contacts the office to reschedule the interview within 30 days from the application filing date.
    

5. When there is a change in payee, in care of addressee, or mailing address.
    

6. When the individual is already a Medicaid recipient in another eligibility category.   

Example:  

An 18-year old individual is removed from the Family Medicaid or Denali KidCare case because of age.  If the 18 year old meets all the financial and non-financial criteria of the Medicaid program that individual may be moved to the Under 21 Medicaid eligibility category without a new application.

7. When an applicant is being added to an ongoing Medicaid case.  All additional forms and documentation needed for that individual (i.e., a 1603, verification of citizenship, etc.) must be obtained before eligibility can be determined.  

Example:  

A cousin moves into the home of a family already receiving Family Medicaid.

8. When an individual is already part of an active public assistance case and the existing case file already includes the information needed to make a prospective Medicaid determination.  The caseworker must carefully document the source of information used to make the eligibility determination.   TPL Third Party Liability or any other missing information should be requested separately.
    

9. When a family moves from Family Medicaid to Transitional Medicaid, or from Transitional Medicaid to Family Medicaid.
    

10. When an applicant originally applied for TEFRA Disabled Child at Home, but at the time of application was only found eligible for FM Family Medicaid or Denali KidCare.  The recipient is not required to file a new application at the time the recipient does move to TEFRA Disabled Child at Home.
     

11. When a household is ineligible for the first month, but eligible for the second month.  See Section 5005-6A.

5005-2 D.   What is an Identifiable Application?

An identifiable application is an acceptable application form containing the applicant’s name, address, and signature (or witnessed mark) of the individual seeking assistance or of the individual's authorized representative.   Each DPA office must accept and date the identifiable application when it is presented.

An individual who contacts a DPA office and who shows interest in the program or a desire to apply shall be advised of his or her right to submit an identifiable application on the date of the contact in order to establish the benefit start date.   The individual may file an identifiable application on an acceptable application form as described at Section 5005-2.

5005-2 E.   Who Can Sign the Application Form?

• An adult household member
   

• A minor parent
   

• An authorized representative
   

• An individual who has legal authority to act on the applicant’s behalf (i.e., Office of Public Advocacy, legal guardian)
   

• An individual with appropriate power of attorney.
   

• A responsible person, if the individual filing the application is incapable of applying and of appointing an authorized representative in writing.
   

• If a child is living with more than one caretaker relative, either of the relatives may be an eligible signer of the DKC application.
   

• The parent, guardian, or the child may sign the Denali KidCare or Under 21 Medicaid application when the caseworker determines it is appropriate.  

Note:  

Any person has a right to submit an application for Medicaid or Denali KidCare and to sign the application form, either for themselves or on behalf of another person.

The signer must certify, under penalty of perjury, the truth of the information contained in the application.

The appropriate individual to sign a Medicaid or Denali KidCare application is a caretaker relative of a dependent child, the authorized representative of a caretaker relative, or, if the caretaker relative is incompetent or incapacitated, a responsible individual acting on behalf of the caretaker relative.   If a child is living with more than one caretaker relative, either of the relatives may be an eligible signer.  When both parents are included in the case, both parents must sign the application.

5005-2 F.   Who can be an Authorized Representative?

A responsible adult, 18 years or older, may be designated by the applicant in writing as authorized representative.  If the applicant is illiterate, his/her mark must be witnessed by two individuals who must each sign their names and date the document.  No special form is required.

Authorized representatives may sign the application and act on behalf of a household.  A household member should prepare or review the application, if possible, even though the authorized representative will be filing the application and/or attending the interview.

5005-2 G.   Completing the Application Form

In addition to making an identifiable application and having it signed by an eligible individual, the applicant must answer all of the questions on the application form.

If the individual requests help in completing the application form, the caseworker will offer assistance.

If the application form is not completed, the caseworker will allow the household an opportunity to complete the form.  In this case, written notification will be sent to the household listing the items that need to be completed.  See Section 5005-6(C), Pending the Application.