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Get CO Medicaid Disability Application Instructions 2021-2024

MEDICAID DISABILITY APPLICATION INSTRUCTIONS THIS FORM MUST BE SUBMITTED TO YOUR COUNTY MEDICAID OFFICE IF YOU NEED HELP If you need help with this form do as much of it as you can and then your county technician will help you finish it. HOW TO COMPLETE THIS FORM The information that you give on this form will be used to decide if you meet the disability criteria for Medicaid benefits in Colorado. Please remember that being found disabled does not guarantee you will receive Medicaid* You must meet all of the eligibility criteria which includes disability. These include 1 disability 2 financial and 3 level of care to receive Medicaid* If you ever applied to the Social Security Administration SSA for Disability Benefits include copies of all letters and notices from SSA. Do not leave answers blank. If you do not know the answer or the answer is none or does not apply please write don t know or none or does not apply. Each address should include a Zip Code. Each phone number should include an Area Code. You must provide complete information for each doctor you identify on this form* Failure to provide complete information may result in those medical records not being used to make a decision on your case. Do not ask a doctor or hospital to complete this form* But you may get help from a friend counselor case manager County Medicaid technician or family member. Be sure to show complete dates month/day/year and explain an answer if the question asks for detail or if you want to give additional information* If you need more space or want to tell us more about an answer please use the REMARKS in Section 8 on page 10. Show the number of the question being answered* You may send copies of any medical records you have with this application* County Date of Application Start Here Section 1 Information About The Disabled Person s A. Name First Middle Initial Last B. Social Security Number C. Mailing Address Street City State and Zip Code D. Daytime Telephone Number If you have no phone where you can be reached give us a daytime number where we can leave a message for you. Your number Message None E* Give the name of a friend or relative that we can contact other than your doctor who knows about your conditions and can help you with your application* Name Relationship Number Street Apt. No* if any P. O. Box or Rural Route City State Zip F* What is your height without shoes H. What is your Date of Birth Phone Feet Pounds Inches Age Sex I. Can you speak English Yes No If No what languages can you speak If you cannot speak English is there someone we may contact who speaks English and will give you a message If this is the same person as in E above write Same here. J* Can you read English K. Can you write more than your name in English Section 2 Your Conditions and How They Affect You A. What are your disabling conditions B. How do your conditions limit your ability to work C. Do your conditions cause you pain or other symptoms D. When did your conditions first bother you 01/2007 - HCPF Month E* When did you become unable to work because of your conditions F* Have you ever worked Day Year If No go to Section 4.

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