ࡱ> uxt{{ 5Objbjzz * D 8n|'o+n0vh(******$,/*]!!!*9+&&&!L(&!(&&&@B!F&'O+0+&k0."(k0&k0&@M 0} "&  M M M **V%NM M M +!!!!k0M M M M M M M M M : FOSTER CARE TRANSITIONAL MEDICAID REFERRALMichigan Department of Human ServicesFCTMA provides Medicaid for eligible youth who were under the responsibility of the Michigan Department of Human Services or Tribal Court with an open foster care case on his/her 18th birthday (refer to FOM 803 or BEM 118 for more information about the FCTMA program).CONTACT INFORMATIONYouth Name: FORMTEXT      Previous Address: FORMTEXT      Address (or where mail can be received): FORMCHECKBOX Current FORMCHECKBOX New AddressDate moving: FORMTEXT       FORMTEXT      Verification (Check if verified):Method of verification (e.g. DL, State ID):County of Residence: FORMCHECKBOX Identity FORMCHECKBOX Residence FORMTEXT       FORMTEXT      Phone Number(s) and Email: FORMCHECKBOX Cell FORMCHECKBOX Home/Other FORMCHECKBOX E-mail FORMTEXT      FORMTEXT       FORMTEXT      FORMTEXT       FORMTEXT      YOUTH ELIGIBILITY CRITERIAFCTMA eligibility requires that the youth is: FORMCHECKBOX Under 21 years of age and FORMCHECKBOX Not currently incarcerated or in a locked facilityAnd at the time of the youth s 18th birthday, he/she was: FORMCHECKBOX Under the responsibility of DHS or tribal court and FORMCHECKBOX In an out-of-home placement.ADDITIONAL INFORMATIONCase Number: FORMTEXT      Recipient ID Number: FORMTEXT      Date of Birth:Method of Verification (e.g. Birth Certificate):Citizenship Verification (e.g. Birth Certificate): FORMTEXT       FORMTEXT       FORMTEXT      Social Security Number:Method of Ver!*,QUqz  # $ ' + , B a b c x 4 6 J L N X Z ^   Ȕvjh\Ujh\Ujh/RUh/RjhP^5Ujh\UmHnHujhP^5Uhh jhh Uhz] hT~5hT~hPhPhLhCmhCmH*hjhCm h%fh%fhZ>h%f.+,RSTsj $Ifgd(,<kdP$$Ifl4,,4 lalf4 $Ifgd%f<kd$$Ifl4,,4 lalf4 $Ifgd%fTUb c w x xl/<kdb$$Ifl4P,,4 lalf4 $$Ifa$gdj<kd$$Ifl4,,4 lalf4 $If^gdP<kd$$Ifl4,,4 lalf4x   4 \ xd$IfgdT~Rkd:$$Ifl40F,F<'4 lalf4yt!$d$IfgdT~d$If^gd\ ^  : b {{d$d$If^a$gd/Rd$If^gd $Ifgd/Rd$If^gddrRkd^$$Ifl40,z%4 lalf4yt!$  : < P R T ^ ` b d f z | ~ P R T V X t v x      źŶ}ڢrڢj0 hmqUjhmqUjFh\Ujh\UhmqjhmqUhpOJQJhmAhpjrhUhjhUh/R5OJQJjh\UmHnHujh ;Uh/Rjh/RU,b d M9d$If^gdkd`$$Ifl4֞HD%,Hhh>4 lalf4yt!$ * T V z SAdd$If^gdxJuekdL$$Ifl4F,    4 lalf4yt!$ $Ifgdp<kd$$Ifl4P,,4 lalf4z  d$If^gdxJud$If^gdmqd$If^gdmqdd$IfgdxJudd$If^gdxJu   L N j l n z |  &(*46:<PRTZ\^`tvxj@hNUjhmAUjThmAUj hmAUjh\UmHnHujh hmAUjT h\Uj h\Ujl h\UjhmAUhmAhmqOJQJhmq3  6 L p z `PP=4 $IfgdZ $d$Ifa$gdZ d$IfgdT~kd $$Ifl4ֈk,_ 4 lalf4yt!$z $Ifgd/R$d$Ifa$gdZ $IfgdZ $d$Ifa$gd ; ,d$IfgdT~kd $$Ifl4֞bHl,`bhhh4 lalf4pF 8: $Ifgd/R $Ifgd ;$d$Ifa$gdZ BDFHdfh(*0lp$*곢}yn}gaUhPhP5>*@ hP@ hdrhPjhPUhPjhPUhdrCJ KH \^JaJ hdrhdrH*hs,*hdr5!hdrCJ KH OJQJ\^JaJ hdrhdr@j6hdrUjhdrUjhdrUhPhdrRHb hdrhdrhdr hmA5hmAjhmAU!, $$Ifa$gdZ>kd$$Ifl4֞bHl, bhhh4 lalf4pFFj( $Ifgddr $Ifgddr $If]gddr?kdV$$Ifl4P,,4 lalf4ytZ>(*sf&?kd$$Ifl4h,,4 lalf4ytP $If]gdPkd$$Ifl4rxP,xh \24 lalf4ytdr,.RCRkdp$$Ifl40\,\&+4 lalf4ytVRkdf$$Ifl40\,\&+4 lalf4ytV $If]gddr $Ifgddr*,.0LNPRTV*,@BDNPRT:<>RTV`bdfz|~ûðû×ÎÉ~ûsûj8hmqUjhmqU hmq5hmq5OJQJjhmqUjh\UmHnHujhhmqUjhmqUhmq hs,*@ hP@jhPUhPjhPUhPCJ KH \^JaJ hdrhP@-*R $IfgdNd$IfgdT~d$IfgdT~<kd$$Ifl4P,,4 lalf4 $$Ifa$gdjRTr:}mmd8$If^gd- $IfgdNxkdF$$Ifl4\,p 4 lalf4yt!$:<dd$IfgdT~ekd<$$Ifl4F,    4 lalf4ytlF6F8FLFNFPFZF\F^F`FtFvFxFFFFFFFFFFFF GGG G"G>G@GBGDGFGbGdGfGhGjGGGGGGGGGڽڲڧڜڑڽچjv!hmqUjh\Uj,h\Ujh\UjDh\U hmq5jhmqUjhmqUUhmqjh\UmHnHujhmqUjhmqU44F6F^F=-d$IfgdT~Rkd$$Ifl40A,AA4 lalf4yt!$ $IfgdNekd$$$Ifl4F,    4 lalf4yt!$ification (e.g. SS Card): FORMTEXT       FORMTEXT      Gender:Race: Ethnicity: FORMCHECKBOX Male FORMCHECKBOX Female FORMDROPDOWN  FORMDROPDOWN Date current Medicaid or medical insurance will end: FORMTEXT      Comments: FORMTEXT      REFERRAL SOURCEName of DHS Foster Care Worker or  FORMCHECKBOX  Other DHS Designee FORMTEXT      (Title)Phone FORMTEXT       FORMTEXT      FORMTEXT      SignatureDate FORMTEXT      Department of Human Services (DHS) will not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, sex, sexual orientation, gender identity or expression, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your area. Foster Care Transitional Medicaid Distribution: Copy for Case File. (800) 343-7320 Send completed copy electronically to:  HYPERLINK "mailto:FCTMA@michigan.gov" FCTMA@michigan.gov or Fax: (517) 432-6079     DHS-57 (Rev. 3-13) Previous edition obsolete. 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