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Fill Out a Valid Florida Dh 3212 Template

The Florida DH 3212 form is a crucial document for individuals seeking to apply for the Health Insurance Application for Extended Family Planning Benefits under a special Medicaid program. It is designed to help eligible applicants receive family planning services by providing necessary personal, health, and financial information to determine their eligibility. The form requires detailed responses about the applicant's health history, household composition, income sources, and insurance coverage, ensuring that those in need can access supportive services to prevent unintended pregnancies.

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Fill Out a Valid Florida Dh 3212 Template

Table of Contents

Finding the right pathway to healthcare services in Florida, especially for family planning, is crucial for many residents. The Florida DH 3212 form plays a pivotal role in this regard, serving as a vital document for those seeking extended family planning benefits through a Special Medicaid Program. This form is meticulously designed to gather detailed information from applicants, covering various aspects such as personal identification, reproductive history, desire for family planning services, household composition, and financial status. It emphasizes the need for applicants to provide their social security number, proof of US citizenship, identity, and details regarding income, all aiming to establish eligibility. Not only does the form inquire about the applicant's current health insurance status and any association with KidCare programs for individuals under 18, but it also requires disclosure of any existing family planning benefits. The completion and submission of this form, along with the required proof of citizenship and financial information, initiate a process where the applicant's eligibility for the Medicaid Family Planning Waiver program is assessed. The program targets those who have lost full Medicaid coverage but still require family planning services, ensuring that income thresholds align with federal poverty levels. From the initial application to the point of certification and authorization, every step detailed in the DH 3212 form underscores the applicant's consent for the Department of Health to access and release their medical and financial information—a process aimed at streamlining the eligibility determination for extended family planning benefits.

Document Preview Example

										Office Date Received
			Health Insurance Application for Extended Family Planning Benefits
					A Special Medicaid Program

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

**Social Security

Date of Birth

Race

Sex

US Citizen?

** If no, give INS

Date of

Applied for

Applicant

Number

Yes

ID Number

Entry

Medicaid?

Yes

(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

Income Source

Gross Income

How Often Are You Paid This Amount?

Additional Information

Receiving Income

(Before Deduction)

(weekly, biweekly, monthly)

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: _________________________________

If you are 18 or under, are you enrolled in any KidCare program?  Yes  No

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, 11/06 Stock No. 5744-000-3212-0

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.

DH 3212

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Document Overview

Fact	Detail
Form Title	Health Insurance Application for Extended Family Planning Benefits
Form Number	DH 3212
Issuing Agency	Florida Department of Health
Eligibility	Applicants who have lost their full Medicaid coverage, have not undergone a hysterectomy or tubal ligation, are not pregnant, desire family planning services, and have an income less than or equal to 185% of the current federal poverty level.
Key Contents	This form collects information including reproductive history, desire to participate in the Family Planning Waiver program, household member details, income sources, and health insurance status.
Required Documentation	Proof of U.S. citizenship, identity, and recent income details for the applicant; additional information as required for household members.
Governing Law(s)	Specific to the Medicaid Family Planning Waiver Program as governed by Florida Statutes and in accordance with Florida and Federal laws regarding the confidentiality of information.

Instructions on How to Fill Out Florida Dh 3212

Filling out the DH 3212 form is a fundamental step to ensure you receive the benefits under the Special Medicaid Program for Extended Family Planning in Florida. It demands your attention to provide accurate and comprehensive information about yourself, your reproductive history, and your family's financial context. Carefully following the instructions for each section will streamline the process and secure the assistance you require.

Start with your complete name (including First Name, M.I., Last Name, and Maiden Name if applicable), your area code, and phone number in the designated spaces.
Under "Residence," fill in your home address details, including the Number, Street, Apt. No., City, County, State, and Zip Code. If your mailing address differs, please specify this in the provided space.
If you don't have a home phone, provide an alternative phone number where you can be reached.
For questions 1 to 3, indicate your reproductive history and whether you wish to receive family planning services by checking the appropriate boxes for ‘Yes’ or ‘No’.
List all people living in your home, beginning with yourself, in question 4. Provide the required information for each individual, including their relationship to you, Social Security Number (for the applicant only), Date of Birth, Race, Sex, and US Citizenship status, together with the INS Date of Entry if applicable.
Question 5 requires you to document the income sources for all household members. Include information for each person’s current job, employer details, other income sources like child support or unemployment benefits, and specify the amount and frequency of this income.
Answer questions 6 to 8 regarding health insurance status, providing the insurance company name if you have coverage and indicating whether your plan includes family planning benefits.
Attach proof of U.S. citizenship and identity as instructed; acceptable documents include a U.S. Passport, Birth Certificate, or other specified forms. Remember, only originals or certified copies are valid.
Read the Certification and Authorization section carefully, then sign and date the form to attest to the accuracy of the information provided and to authorize the release of your information for the purpose of determining eligibility.
Finally, mail or bring your completed application to your local county health department. The address for this can be found on the attached list included with the form. Note that this application should not be sent to Medicaid directly.

This form is a critical component of accessing beneficial services that support your family planning goals. By meticulously completing and submitting the DH 3212 form, you move closer to obtaining the support you are seeking. Remember, accuracy and completeness are key in this process. Your attention to detail will help avoid delays and ensure that your application is processed efficiently.

Listed Questions and Answers

What is the purpose of the Florida DH 3212 form?

The Florida DH 3212 form is an application used to determine eligibility for the Medicaid Family Planning Waiver program. This program is designed for individuals who have lost their full Medicaid benefits and are seeking family planning services but do not currently have the means to obtain them. The program aims to provide extended family planning benefits to help prevent unwanted pregnancies and support the overall health of those eligible.

Who is eligible to apply using the Florida DH 3212 form?

Eligibility for the Medicaid Family Planning Waiver program, as applied through the Florida DH 3212 form, includes individuals who have lost their full Medicaid coverage, have not undergone a hysterectomy or tubal ligation, are not pregnant, wish to receive family planning services, and whose income is less than or equal to 185% of the current federal poverty level. This helps ensure that family planning services are accessible to those who are in need and meet certain criteria.

What information do I need to provide on this application?

When completing the Florida DH 3212 application, you will need to provide detailed information about yourself and other household members. This includes your name, contact information, reproductive history, details about the people who live in your home, your income sources, and any health insurance you currently have. Specifically, the applicant must provide their Social Security Number, proof of U.S. citizenship and identity, and proof of income. Other household members must also provide information about their income sources and amounts.

Do I need to attach any documents to my Florida DH 3212 application?

Yes, when submitting your Florida DH 3212 application, you are required to attach proof of US citizenship and identity. Acceptable documents include a U.S. Passport, a U.S. Birth Certificate, Form FS-240, Report of Birth Abroad of a Citizen of the U.S., Form FS 545, or Form DS1350, Certification of Birth Abroad. Remember, only originals or certified copies are accepted to verify your citizenship and identity.

What happens after I submit the application?

After submitting the Florida DH 3212 application to your local health department, your application will be reviewed to determine your eligibility for the Medicaid Family Planning Waiver program. You may be contacted by phone if additional information is needed. Otherwise, notification about your eligibility status will be sent to you by mail. It is important to ensure that your contact information is accurate and up-to-date to receive this information promptly.

Can I submit the Florida DH 3212 form to Medicaid directly?

No, you should not send the Florida DH 3212 form directly to Medicaid. The instructions specifically state to mail or bring your completed application and any accompanying documents to your local county health department. The local health department will process your application and coordinate with Medicaid as necessary. Check the form or with your local health department for the appropriate address or location where you should submit your application.

Common mistakes

Filling out government documents can be a daunting task, especially when it comes to applying for benefits. The Florida DH 3212 form, which is an application for the Health Insurance for Extended Family Planning benefits, is no exception. Applicants often encounter several stumbling blocks that can hinder the processing of their application. Understanding these common mistakes can significantly improve the chances of a successful application. Here are seven common mistakes people make:

Not providing complete information for questions 1 through 3 that inquire about reproductive history and desire to participate in the Family Planning Waiver program. Every question serves a purpose and requires an answer to process the application properly.
Failure to list all individuals living in the household under question 4, including their relationship to the applicant, and for the applicant alone, the requirement for a Social Security number and proof of citizenship if claiming U.S. citizenship.
Omitting income details for all members in the household who have an income, as requested in question 5. This includes not specifying the income source, gross income before deductions, and how often one is paid. This comprehensive income information is critical for determining eligibility.
Neglecting to provide or confirm health insurance information in questions 6 through 8, which is crucial for evaluating eligibility for the Extended Family Planning benefits program.
Forgetting to attach proof of U.S. citizenship and identity as detailed under requirement 9. The application specifies that only originals or certified copies are accepted, a detail often overlooked.
Incorrectly or not signing and dating the Certification and Authorization section. This formal acknowledgment is essential to authorize the Department of Health to process the application.
Sending the application to the wrong place, as explicitly stated not to send it to Medicaid but rather to the local county health department.

In summary, paying close attention to the requirements and questions posed on the Florida DH 3212 form is vital for a smooth application process. Mistakes can delay or even prevent access to the needed benefits. By avoiding these common errors, applicants improve their chances of a successful application.

Documents used along the form

When applying for the Florida DH 3212 form, which is the Health Insurance Application for Extended Family Planning Benefits, applicants often need to complement this application with other forms and documents to ensure their eligibility and facilitate the processing of their application. These additional documents not only help in establishing identity and residency but also in proving income and evaluating the need for the benefits.

Proof of U.S. Citizenship and Identity: To satisfy the requirement mentioned in the DH 3212 form, applicants can use a U.S. Passport, a Birth Certificate, or other forms such as Form FS-240, FS 545, or DS 1350. These documents confirm the applicant's citizenship status, which is critical for eligibility.
Proof of Income: This could include recent pay stubs, tax returns, or employer verification letters. Since eligibility for the Family Planning Waiver Program depends on income being below a certain threshold, providing accurate income information is vital.
Proof of Residence: Documents like utility bills, rental agreements, or a driver's license with the current address help establish Florida residency. This information ensures that applicants are applying within the correct jurisdiction for state-specific benefits.
Insurance Policy Documentation: If an applicant states that they have health insurance (Question 6), providing policy details or an insurance card can help the department verify coverage and understand how it might coordinate with the offered services.
Medical Documentation: For any applicant who has answered "Yes" to having had a hysterectomy or tubal ligation, medical records detailing these procedures may be required. This information is crucial as it directly influences eligibility for the family planning services.
KidCare Program Enrollment Verification: For those under 18 who are enrolled in any KidCare program, as referenced in Question 7, documents showing current enrollment status can assist in the application process. This helps avoid overlap in benefits and ensures appropriate assistance.

The preparation and submission of these documents alongside the Florida DH 3212 form are steps in ensuring that individuals seeking extended family planning benefits through Medicaid can avail themselves of these valuable services. It's important for applicants to provide thorough and accurate information to streamline the approval process. Gathering these documents in advance can help reduce delays and facilitate a smoother application process for family planning waiver benefits.

Similar forms

The Florida DH 3212 form, titled Health Insurance Application for Extended Family Planning Benefits, is similar to a number of other documents used within the healthcare and social services sectors to assess eligibility and facilitate access to various programs. It gathers comprehensive personal, financial, and medical information to determine eligibility for the Medicaid Family Planning Waiver program. The nature of the information requested on this form echoes that of other healthcare-related forms, albeit with a specific focus on family planning services.

One such similar document is the Application for Health Coverage & Help Paying Costs (Form CMS-40B). This form is utilized to apply for health insurance through the Health Insurance Marketplace, allowing individuals and families to find out if they qualify for private insurance plans with premium tax credits and other savings, Medicaid, or the Children’s Health Insurance Program (CHIP). Both the DH 3212 and CMS-40B forms require applicants to disclose detailed personal and financial information to assess eligibility. Where they differ primarily is in their specific program focus; while the DH 3212 form is targeted towards extended family planning services under Medicaid, the CMS-40B is broader in its application, catering to a wide array of health coverage options.

Another document with similarities is the Supplemental Nutrition Assistance Program (SNAP) application form. Although the SNAP form is designed to assess eligibility for food assistance benefits rather than healthcare services, both this form and the DH 3212 require applicants to provide household income details, employment information, and personal identification to confirm eligibility. They both also inquire about the number of people living in the household and their financial contributions, reflecting the programs’ interest in understanding the applicant's broader economic context to offer appropriate assistance. The key distinction lies in the nature of benefits they aim to provide; the SNAP application seeks to address nutritional needs, while the DH 3212 focuses on family planning healthcare services.

Lastly, similarities can be drawn with the Children’s Health Insurance Program (CHIP) application form. The CHIP application is designed to help families obtain low-cost health insurance for children in families that earn too much money to qualify for Medicaid but not enough to afford private health insurance. Like the DH 3212 form, it includes sections for personal details, household composition, and income verification. Both forms aim to extend healthcare coverage to underserved populations, though the DH 3212 has a specific emphasis on family planning services, contrasting with CHIP's broader child health services coverage.

Dos and Don'ts

When filling out the Florida DH 3212 form, it's essential to pay attention to details and follow specific do's and don'ts to ensure your application is processed efficiently and correctly. Here are five key things you should and shouldn't do:

Do:

Provide accurate personal information: Ensure details like your name, address, and social security number are correctly filled in to avoid delays.
Answer all questions truthfully: The questions, especially regarding your reproductive history and desire for family planning services, need honest answers.
Include all required documentation: Attach proof of U.S. citizenship, identity, and any other documents the form specifies are necessary.
Print clearly: All the information you provide should be legible to prevent misinterpretations of your application content.
Sign and date the form: Your signature is crucial for the application's validity, so don't forget to sign and date it as instructed.

Don't:

Leave sections blank: If a question doesn't apply to you, write 'N/A' instead of leaving it empty to indicate you've reviewed it.
Provide incomplete documentation: Submitting only parts of the required documentation can lead to applications being delayed or denied.
Guess on dates or numbers: If you're unsure about specific details, it's better to confirm first rather than guess, to avoid incorrect information.
Ignore the income section: Even if you think it's not applicable, detail your income sources accurately, as this affects eligibility.
Send it to the wrong place: Make sure to mail or bring your application to your local county health department, not to Medicaid directly.

Misconceptions

When it comes to navigating health insurance applications, understanding the specific requirements and benefits available can be challenging. The Florida Department of Health's DH 3212 form, designed for the Health Insurance Application for Extended Family Planning Benefits, often carries with it several misconceptions. Shedding light on these can help ensure that individuals are accurately informed and can access the benefits they need without unnecessary hurdles.

1. Misconception: The DH 3212 form is only for females.

This is a common misunderstanding. While the form indeed focuses on services that appear gender-specific, such as family planning, it is important to recognize that the eligibility for these benefits does not solely depend on gender. The form is designed to provide extended family planning benefits under a special Medicaid program to eligible individuals who meet certain criteria, including income and specific health conditions, irrespective of their gender.

2. Misconception: You must be unemployed to apply.

Another misconception is the belief that only unemployed individuals are eligible to apply using the DH 3212 form. In fact, eligibility for the program is based on income level rather than employment status. Applicants who are under the 185% federal poverty level may qualify for benefits, regardless of whether they are employed or unemployed. The form requires information about income sources and amounts to help determine this eligibility.

3. Misconception: If approved, the DH 3212 form covers all medical expenses.

Some applicants might mistakenly believe that approval for the Medicaid Family Planning Waiver program covers all medical expenses. However, it's imperative to understand that the program is specifically designed to cover family planning services, such as contraception and counseling. It does not extend to broader medical services or comprehensive health care coverage.

4. Misconception: Once submitted, no further action is required.

Submitting the DH 3212 form is indeed an important step, but it's sometimes incorrectly assumed to be the final one. Applicants may be required to provide additional documentation or clarification regarding their eligibility. The local health department may also reach out by phone or mail to request further information or to inform applicants of their eligibility status. Hence, it's crucial for applicants to stay attentive to any communication after submission.

5. Misconception: The DH 3212 application process is lengthy and complicated.

While it's true that the application requires detailed information, the perception that the process is excessively lengthy and complex may deter some from applying. The form is structured to guide applicants through providing necessary information related to their eligibility. Following the instructions and having required documents ready can streamline the process, making it less daunting than it might initially seem.

In conclusion, clarifying these misconceptions about the Florida DH 3212 form aims to ease the application process for individuals seeking family planning benefits through the Medicaid program. With accurate information, eligible individuals can more effectively navigate the requirements and take full advantage of the available benefits.

Key takeaways

Filling out the Florida DH 3212 form correctly is essential for applying for the Health Insurance Application for Extended Family Planning Benefits. To ensure a smooth process and enhance understanding, here are four key takeaways:

Eligibility Requirements: To qualify for the Medicaid Family Planning Waiver program, applicants must not be pregnant, have had a full Medicaid loss, and have not undergone a hysterectomy or tubal ligation. Desire for family planning services and having an income less than or equal to 185% of the current federal poverty level are also crucial eligibility criteria.
Application Completion: Accurately completing the application, including answering questions 1-9, is vital. The form requires detailed information about the applicant's reproductive history, desire to participate in the Family Planning Waiver program, household members, income sources, and insurance status. Failing to complete the application or providing incomplete information may delay the benefits determination process.
Documentation Requirement: Applicants must provide their social security number, proof of U.S. citizenship and identity, and evidence of income, such as pay stubs from the last four weeks if employed. It is emphasized that only originals or certified copies will be accepted as proof of U.S. citizenship and identity. These documents play a critical role in verifying the information provided in the application, thus affecting the eligibility determination.
Submission Guidelines: The completed form, along with any required documentation, should be submitted to the local county health department. Applicants are instructed not to send their applications directly to Medicaid but instead to refer to the attached list for the appropriate local health department contact information. Timely submission is crucial to avoid delays in benefit determination and commencement of family planning services under the waiver program.

Understanding and adhering to these points is essential for applicants seeking eligibility and benefits under the Medicaid Family Planning Waiver program. By following these guidelines, applicants can ensure the timely and efficient processing of their applications.

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