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  • Health Care Application For Exteded Family Planning Benefits Form

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Area Code ( ) County Mailing Address (Required if different from above): **Only the applicant must provide her Social Security Number and her proof of citizenship and identity. M.I. Last Relationship to **Social Security Date of Birth Race Sex US Citizen? Applicant Number Yes No State Zip Code 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 l.

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Health education, cancer screenings, STI testing and treatment, pregnancy and preconception screening. Oftentimes, states also include sexual and reproductive health education programs and testing and treatment for sexually transmitted infections (STIs) in their family planning coverage, too.

Family Planning Services include: Most FDA approved birth control methods, devices, and supplies (e.g., birth control pills, injectables, or patches, condoms, diaphragms, IUDs) Emergency contraception services and follow up care.

Family Planning is a limited benefit program, which provides coverage for preventive health care, family planning services and family planning-related services. ... This means you may have to pay a tax penalty if you do not have other health insurance coverage.

Under COE 029 an eligible recipient (male or female) is covered for services, consultations and supplies related to birth control, pregnancy prevention and family planning related services which are prescribed and furnished by physicians, hospitals, clinics, pharmacies, and other Medicaid providers.

Pregnant, or. Be responsible for a child 18 years of age or younger, or. Blind, or. Have a disability or a family member in your household with a disability, or. Be 65 years of age or older.

3.2.1 Specific criteria covered by both Medicaid and NCHCFamily planning services consist of consultation, examination, laboratory tests, FDA approved contraceptive methods, supplies, and devices to prevent conception, as described in this policy.

Family planning services and supplies are those services and supplies whose primary purpose is family planning and which are provided in a family planning setting, such as approved methods of contraception, sexually transmitted infection (STI)/sexually transmitted disease (STD) testing, Pap smears and pelvic exams, ...

The test may be covered once every 12 months for women at high risk. Your doctor will usually do a pelvic exam and a breast exam at the same time.

Services You Can Receive An annual medical exam by a physician. This may include a medical history, height, weight and blood pressure checks, and for women, a Pap smear and clinical breast exam.

This program provides coverage for family planning-related health care including: Most FDA approved birth control methods, devices, and supplies including birth control pills, condoms, the patch, , IUDs and . Emergency contraception and follow-up care.

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© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232
Form Packages
Adoption
Bankruptcy
Contractors
Divorce
Home Sales
Employment
Identity Theft
Incorporation
Landlord Tenant
Living Trust
Name Change
Personal Planning
Small Business
Wills & Estates
Packages A-Z
Form Categories
Affidavits
Bankruptcy
Bill of Sale
Corporate - LLC
Divorce
Employment
Identity Theft
Internet Technology
Landlord Tenant
Living Wills
Name Change
Power of Attorney
Real Estate
Small Estates
Wills
All Forms
Forms A-Z
Form Library
Customer Service
Terms of Service
Content Takedown Policy
About Us
Blog
Affiliates
Contact Us
Privacy Notice
Delete My Account
Site Map
Industries
Forms in Spanish
Localized Forms
State-specific Forms
Forms Kit
Legal Guides
Real Estate Handbook
All Guides
Prepared for You
Notarize
Incorporation services
Our Customers
For Consumers
For Small Business
For Attorneys
Our Sites
US Legal Forms
USLegal
FormsPass
pdfFiller
signNow
airSlate workflows
DocHub
Instapage
Social Media
Call us now toll free:
+1 833 426 79 33
As seen in:
  • USA Today logo picture
  • CBC News logo picture
  • LA Times logo picture
  • The Washington Post logo picture
  • AP logo picture
  • Forbes logo picture
© Copyright 1997-2025
airSlate Legal Forms, Inc.
3720 Flowood Dr, Flowood, Mississippi 39232