Application for Services

SM

What do I need to do to get benefits?

1. Pick up an application (MSC 0415F). You can get an application by: Printing one from https://apps.state.or.us/Forms/Served/me0415F.pdf; Calling your local self-sufficiency office to have one mailed to you, or; Picking one up at your local self-sufficiency office. To find the closest office, call Oregon SafeNet at 1-800-723-3638 or go online to http://egov.oregon.gov/DHS/localoffices/localoffices.pdf. Child care, Employment Related Day Care (ERDC): For low income working families; more information can be found at the following website: http://cms.oregon.gov/dhs/children/Pages/childcare/index.aspx To apply, fill out pages 14. Read pages 1618 and sign page 18. Food benefits, Supplemental Nutrition Assistance Program (SNAP): Help to buy food. To apply, fill out pages 16. Read pages 1518 and sign page 18. You can submit pages 1 and 2 to start the application process. Medical assistance: For low income individuals or families who meet all eligibility requirements for a medical program. Cash assistance, Temporary Assistance for Needy Families (TANF): For very low income families with dependent children, or who are in the late stages of pregnancy. To apply for medical or cash assistance, fill out the entire application. 3. Turn in the application. You can mail, fax or drop the application off at your local self-sufficiency office (You can make a date-stamped copy for your records). 4. Make an appointment for an interview with a caseworker. We may go over the application with you in an interview. It is important to make it to your interview. If you need to reschedule, please let us know. No interview is required for medical benefits. Continued on next page

2. Fill out the application.

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5. Information for medical applicants: There may be a Coordinated Care Organization (CCO) available in your community (see questions 14 and 15 on page 10 of this application). CCOs are local networks of doctors, mental health providers, hospitals and other providers. They work together for patient-centered care for people on the Oregon Health Plan and Healthy Kids.

What if I need food benefits right away?

Read more about CCOs at www.health.oregon.gov.

We may be able to give you food benefits within seven days if you qualify. To qualify, one of the following must be true: Your income is less than $150 per month and your cash and bank accounts total less than $100; The total of your monthly income, cash and money in the bank is less than your total housing and utility costs for a month; You are a migrant or seasonal farm worker and have very little money. You must be able to show proof of your identity.

What do I need to bring to the interview?

You will need to bring: 1. Your identification; 2. Proof of your income, rent and mortgage payments; 3. Social Security numbers or cards for everyone in your household who wants benefits; 4. Proof of your legal status or citizenship for those persons who want benefits. Please let us know if you need help getting the information and we can help you.

When will my benefits start if I qualify?

Cash benefits start on the date we get all the information to decide that you qualify. Food benefits usually start based on the date we get the application. The amount of our benefits is also based upon this date. Medical benefits start depending upon which program you qualify for and the date we get your application. You may also ask for help with some past medical bills. Child care benefits start on the first day of the month in which the request is made if you qualify.

Social Security numbers (SSN) and citizenship.

If you are applying for someone else, and not for yourself, we do not need your SSN or citizenship status. People who are not U.S. citizens may still qualify for certain benefits. If you do not have an SSN yourself, other family members who do have SSNs may still qualify. Page 16 tells why the Department of Human Services (DHS) and the Oregon Health Authority (OHA) collects each SSN and what each SSN is used for.

This document can be provided upon request in alternate formats for individuals with disabilities or in a language other than English for people with limited English skills. To request this form in another format or language, contact your local office or 711 for TTY. For a list of local offices please see www.oregon.gov/ DHS/localoffices/index.shtml.

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Agency Use Only: Appointment date/time: Expedited service? Yes No Alternate format? Yes No What format? AT Braille CD LP OP

Date of request: Interpreter? Yes No What language?

Filing date: MA notice

Please ask if you need help filling out this form.

Let us know if you need: c An interpreter. Language I speak: ___________________________________________________ c A sign language interpreter c Written materials translated (what language): ____________________________________________ Materials in: c Braille c Large print c Audio tape c Computer disk c Oral presentation

Tell us about you

Full name
Social Security Home address Mailing address (if different) (last, first, middle initial) Phone number City City Maiden (or other names used) Message number State State ZIP code ZIP code

If you are not registered to vote where you live now, would you like to register to vote today? Yes No Applying to register or declining to register to vote will not affect the amount of assistance you will be provided by this agency. 1. I am applying for: Child care Domestic violence help Food Medical Cash for families 2. Do you plan to stay in Oregon? Yes No 3. Has anyone you are applying for received services from another state within the last 30 days? Yes No If yes, where?_________________________ Date last received: _________________________ 4. Do you want to give permission to someone else to apply or get benefits for you? Yes No 5. Do you usually buy food and eat with everyone you live with? Yes No If no, who buys their food separately?___________________________________________________ 1. Please answer the following for you and anyone you are applying for. a) Does anyone have income of $150 or more a month? Yes No b) Does anyone have $100 or more in cash, checking or savings accounts? Yes No c) Are your monthly rent and utility payments more than your monthly income, cash and money in your bank accounts? Yes No d) Is anyone a migrant or seasonal farm worker? Yes No If yes, does anyone have $100 or more in cash, checking or savings? Yes No Will you get income of $25 or more in the next 10 days? Yes No 2. Do you need a place to live? Yes No 3. Do you have an eviction or foreclosure notice? Yes No 4. Do you have or expect to get a utility shut-off notice? Yes No 5. For cash benefits, would you like to talk with someone about concerns you have with your children? (Such as acting out, school problems, medical needs or finding child care.) Yes No 6. Do you need to get away from an abusive or unsafe situation? Yes No 7. Does your partner make you afraid by threatening, yelling or physically hurting you Yes No or your children?
Agency use only: Case name: Program: Branch: Case number: Worker ID: Receptionist ID:

Do you have an immediate need?

1 1

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Please complete below for everyone in your household. You can choose not to give your ethnic group and racial heritage information. It will not affect your eligibility. This information helps us follow Title VI of the Civil Rights Act of 1964.
Full name (last, first, middle initial) Date of birth (mm/dd/yyyy) Sex: Male Female

1. Tell us about the people in your household

Please answer below for those who want benefits. Check the box of benefits you are applying for this person.
Check below the benefits for this person. None Food Child care Medical Cash Domestic violence help For food and cash benefits, does this person have an outstanding arrest warrant? Yes No Social Security number: U.S. citizen? Yes No, If no and this person has an Alien Resident number, enter below: Place of birth? ____________________________________ (City/state or country) Last grade completed? _____________________ Check below the benefits for this person. None Food Child care Medical Cash Domestic violence help For food and cash benefits, does this person have an outstanding arrest warrant? Yes No Social Security number: U.S. citizen? Yes No, If no and this person has an Alien Resident number, enter below: Place of birth? ____________________________________ (City/state or country) Last grade completed? _____________________

Relationship (mother, son)

Self

Marital status: Married Single Widowed Divorced Married, but separated Ethnicity: Hispanic/Latino Not Hispanic/Latino Racial heritage: Asian White Native Hawaiian/Pacific Islander American Indian/Alaska Native Black or African American Full name (last, first, middle initial) Date of birth (mm/dd/yyyy) Sex: Male Female Marital status: Married Single Widowed Divorced Married, but separated Ethnicity: Hispanic/Latino Not Hispanic/Latino Racial heritage: Asian White Native Hawaiian/Pacific Islander American Indian/Alaska Native Black or African American Relationship (mother, son)

If you need additional space, see the next page. 2. Is anyone in your household pregnant? Yes No If yes, who? _________________________________________ Due date: __________________ 3. List anyone who wants benefits and is a high school, college, trade or vocational student. Student 1 Name of student: Name of school/training program: High school GED Graduate Type of student:
Vocational Undergraduate This term Getting

Student 2

High school GED Graduate Vocational Undergraduate This term Getting Both

Credits: Student last term, this term or both? Last term Apply Apply for or get financial aid? 4. Full legal signature of applicant

Both Last term Apply

Date

To complete your application for food benefits, fill in pages 3 6.

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Please complete below for everyone in your household. You can choose not to give your ethnic group and racial heritage information. It will not affect your eligibility. This information helps us follow Title VI of the Civil Rights Act of 1964.
Full name (last, first, middle initial) Date of birth (mm/dd/yyyy) Sex: Male Female

Additional space for other people living with you

Please answer below for those who want benefits. Check the box of benefits you are applying for this person.
Check below the benefits for this person. None Food Child care Medical Cash Domestic violence help For food and cash benefits, does this person have an outstanding arrest warrant? Yes No Social Security number: U.S. citizen? Yes No, If no and this person has an Alien Resident number, enter below: Place of birth? ____________________________________ (City/state or country) Last grade completed? _____________________ Check below the benefits for this person. None Food Child care Medical Cash Domestic violence help For food and cash benefits, does this person have an outstanding arrest warrant? Yes No Social Security number: U.S. citizen? Yes No, If no and this person has an Alien Resident number, enter below: Place of birth? ____________________________________ (City/state or country) Last grade completed? _____________________ Check below the benefits for this person. None Food Child care Medical Cash Domestic violence help For food and cash benefits, does this person have an outstanding arrest warrant? Yes No Social Security number: U.S. citizen? Yes No, If no and this person has an Alien Resident number, enter below: Place of birth? ____________________________________ (City/state or country) Last grade completed? _____________________

Relationship (mother, son)

Marital status: Married Single Widowed Divorced Married, but separated Ethnicity: Hispanic/Latino Not Hispanic/Latino Racial heritage: Asian White Native Hawaiian/Pacific Islander American Indian/Alaska Native Black or African American Full name (last, first, middle initial) Date of birth (mm/dd/yyyy) Sex: Male Female Marital status: Married Single Widowed Divorced Married, but separated Ethnicity: Hispanic/Latino Not Hispanic/Latino Racial heritage: Asian White Native Hawaiian/Pacific Islander American Indian/Alaska Native Black or African American Full name (last, first, middle initial) Date of birth (mm/dd/yyyy) Sex: Male Female Marital status: Married Single Widowed Divorced Married, but separated Ethnicity: Hispanic/Latino Not Hispanic/Latino Racial heritage: Asian White Native Hawaiian/Pacific Islander American Indian/Alaska Native Black or African American Relationship (mother, son) Relationship (mother, son)

* If you need additional space, see the back of this sheet.

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Please complete below for everyone in your household. You can choose not to give your ethnic group and racial heritage information. It will not affect your eligibility. This information helps us follow Title VI of the Civil Rights Act of 1964.
Full name (last, first, middle initial) Date of birth (mm/dd/yyyy) Sex: Male Female

Additional space for other people living with you

Please answer below for those who want benefits. Check the box of benefits you are applying for this person.

Check below the benefits for this person. None Food Child care Medical Cash Domestic violence help For food and cash benefits, does this person have an outstanding arrest warrant? Yes No Social Security number: U.S. citizen? Yes No, If no and this person has an Alien Resident number, enter below: Place of birth? ____________________________________ (City/state or country) Last grade completed? _____________________ Check below the benefits for this person. None Food Child care Medical Cash Domestic violence help For food and cash benefits, does this person have an outstanding arrest warrant? Yes No Social Security number: U.S. citizen? Yes No, If no and this person has an Alien Resident number, enter below: Place of birth? ____________________________________ (City/state or country) Last grade completed? _____________________ Check below the benefits for this person. None Food Child care Medical Cash Domestic violence help For food and cash benefits, does this person have an outstanding arrest warrant? Yes No Social Security number: U.S. citizen? Yes No, If no and this person has an Alien Resident number, enter below: Place of birth? ____________________________________ (City/state or country) Last grade completed? _____________________

Relationship (mother, son)

Marital status: Married Single Widowed Divorced Married, but separated Ethnicity: Hispanic/Latino Not Hispanic/Latino Racial heritage: Asian White Native Hawaiian/Pacific Islander American Indian/Alaska Native Black or African American Full name (last, first, middle initial) Date of birth (mm/dd/yyyy) Sex: Male Female Marital status: Married Single Widowed Divorced Married, but separated Ethnicity: Hispanic/Latino Not Hispanic/Latino Racial heritage: Asian White Native Hawaiian/Pacific Islander American Indian/Alaska Native Black or African American Full name (last, first, middle initial) Date of birth (mm/dd/yyyy) Sex: Male Female Marital status: Married Single Widowed Divorced Married, but separated Ethnicity: Hispanic/Latino Not Hispanic/Latino Racial heritage: Asian White Native Hawaiian/Pacific Islander American Indian/Alaska Native Black or African American Relationship (mother, son) Relationship (mother, son)

* If you need additional space, please make copies or ask for the MSC 0415X.

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Agency use only

Program:

Branch:

Case number:

Case name:

Worker ID:

Tell us about your households income

Please answer the following for you and anyone you are applying for. 1. Does anyone have or expect to get any money? Yes No If yes, please answer questions 2 and 3. We will need proof of income. For food, cash and child care benefits, we will need proof of income for the last 30 days. For medical benefits, please send a copy of the most recent pay stub or a pay stub received within the last 30 days for each job listed.

2a. Money from work. Please tell us about wages, salaries and commissions for this month from jobs. We need to know about money that has already been paid or that will be paid this month to anyone in your home who is related to you or your children (including expected children). Use gross income (totals before taxes and deductions). Does anyone in your home get money for working? Yes No If yes, please fill out this page. Self-employment means you are being paid for doing work, but you dont have a regular employer other than yourself who gives you a paycheck and takes out taxes. Perhaps you have your own company with a separate bank account, or perhaps you do odd jobs for people who pay you in cash. Does anyone in your home get money for self-employment? Yes No If yes, add income below. Do you have any costs associated with this business? Yes No Earned income Job 1 Job 2 Person working: Employers name: Employers phone: Hourly pay: $ $ $ Hours (per week): How often paid (weekly, monthly): Income this month: $ $ $ Income last month: $ $ $ *If any income has recently changed or will be changing, please let us know why: Job 3

New amount: Date of the change:

$ Yes No

2b. Has anyone lost a job or quit a job within the last 30 days?

If yes, who? ______________________________________ Date of job loss/change? ____________ Reason for job loss? _________________________________________________________________ Date of last pay: ____________________________________________________________________

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3. Please list any unearned income. Yes No Does anyone in your home get money from places other than work? If yes, tell us about this months income for anyone in your home who is related to you or your children (including expected children). You must send proof. Tell us about money, including: rent paid to you disability benefits dividends or interest loans repaid to you child or spousal support on investments TANF (Temporary guardian or foster workers compensation Assistance for care payments tribal payments Needy Families) Social Security benefits unemployment compensation retirement pension Supplemental Security educational income (such as veterans benefits Income (SSI) financial aid) Other: Unearned income Person receiving the money: Source/type: Expected to continue: Amount received: How often received (weekly, monthly): Unearned income this month: Unearned income last month: 1 2 3

Yes

No

Yes

No

Yes

No

$ $

$ $

$ $

Tell us about your households expenses Dependent care expenses

Yes No 1. Does anyone pay for child care or care for an adult with a disability? If yes, who pays? ____________________________ $ ______________ a month. 2. If you get child care benefits, do you pay for child care costs in addition to your copay? Yes No If yes, enter monthly amount. $ ______________ a month. 3. For child care needs, please list information about your work schedule and care providers.
Usual work hours: From Usual work days: Mon. Tue. Other schedule (describe): Care provider: Phone number: Phone number: a.m. / p.m. Wed. To Thu. Fri. a.m. / p.m. Sat. Sun.

Second provider:

Yes No 4. For child care needs, are your childrens immunization (shot) records up-to-date? If no, contact your doctor or local health department for more information. You must agree to meet state immunization guidelines to get child care benefits.

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If you are applying for child care only, please skip to page 16, read pages 16-18 and sign page 18. To apply for food, cash or medical benefits, please continue.

Housing expenses
5. Do you or anyone in your household pay for housing? If yes, please complete below.
Rent Mortgage What is the total rent/mortgage? ___________________

Yes

No

How much do you pay of the Fire/hazard insurance, Property tax, if separate: total amount? if separate: $________________ per $________________ per $________________ per Week Month Year Week Month Year Week Month Year Person or company you pay rent/mortgage to: May we contact this person/company? Yes No If yes, their phone: 6. Do you expect to pay the same amount for housing next month? 7. Do you get help to pay for housing? If yes, please complete below.
Who pays Paid to

Yes Yes

No No

Amount paid

$ $ 8. If you have reported that you have no income, how are you paying your housing expenses? _________________________________________________________________________________ _________________________________________________________________________________

Utility expenses
9. Do you pay to heat/cool your home? a) Is the heat/cool expense included in the rent/mortgage? 10. What other kind of utilities do you pay? Water/sewer Garbage Electric Gas Phone Yes No Yes No Other: __________________

Court-ordered child support expenses

11. Does anyone in your home pay court-ordered child support to someone outside your home? Yes No If yes, please complete below.
Person who pays support For which child Amount paid

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Medical expenses
12. Does anyone have medical expenses now or from the last three months? Yes No Yes No 13.Is anyone you are applying for 60 or older or a person with a SSI/SSD disability? If yes, list any out-of-pocket medical expenses, including medical insurance expenses. Person with the out-of-pocket expenses $ Amount paid
a month

Tell us about your households resources

1. Do you, or anyone you are applying for own or have their name on any of the following? Yes No Yes No a) Checking, savings, credit union accounts, IRA, 401K. b) Stocks, bonds, money market accounts, CDs, trust funds. If yes to any of the above, please complete below. Type Name/location of bank Current balance/value Belongs to Yes No c) Cash on hand or other: _________________________________________________________

2. Is anyone buying, or an owner of, real estate, land or buildings you are not living on? Yes No 3. Does anyone have any items of value? (examples: car, truck, boat, etc.) If you are applying for food and child care benefits only, skip to page 15. Read pages 15 18 and sign page 18. To apply for cash or medical benefits, please continue. Yes No

Agency use only

FUA

LUA

IUA

TUA

COS

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Tell us about any parents not living in your household

Important By applying for services, you are letting us establish paternity (legally name the childs father) and pursue health care coverage, medical cash support and child support from parents not living in your household unless you think this parent might harm you or the child. Yes No 1. If anyone in your household is pregnant, is the father living in the house? Yes No 2. Do any of the childrens parents live outside the childs home? If yes, please list parent(s) even if the child has not been born yet. Also, list your parents if you are under 18 and not living with them. Please give as much information as possible. a) Absent parent 1 Name (first, middle initial, last): This is my: c spouse or ex-spouse c child c partner or ex-partner c step child c other: _________________________________

Sex: c Female Date of birth: (month, day, year): Social Security number (if you know it): c Male Address: City: Phone:

State:

ZIP code:

Date this parent stopped living with child (month, day, year): List this parents child(ren) whom you have written about on this application.

*Please make copies of this page for additional parents.

Number of hours each week this parent spends with the child(ren): How many of these hours are spent in the child(ren)s home: If this is an absent father, has paternity been legally established? c Yes c No c I dont know Can the child or children get health insurance through this parent? c Yes c No c I dont know Do you think this parent might hurt you or the child if we try to find out about paternity or health insurance? c Yes c No b) Absent parent 2 Name (first, middle initial, last):

This is my: c spouse or ex-spouse c child c partner or ex-partner c step child c other: _________________________________

Sex: c Female Date of birth: (month, day, year): Social Security number (if you know it): c Male Address: City: Phone:

State:

ZIP code:

Date this parent stopped living with child (month, day, year): List this parents child(ren) whom you have written about on this application.

Number of hours each week this parent spends with the child(ren): How many of these hours are spent in the child(ren)s home: If this is an absent father, has paternity been legally established? c Yes c No c I dont know Can the child or children get health insurance through this parent? c Yes c No c I dont know Do you think this parent might hurt you or the child if we try to find out about paternity or health insurance? c Yes c No

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Tell us about your households employment/disabilities

1. Does anyone have a disability or a condition that, without treatment, would be Yes No life-threatening or would cause permanent loss of function or disability? If yes, who? ____________________________________________________________________ 2. Does anyone have a disability that makes him/her unable to work at their old job or Yes No unable to care for their children? If yes, who? ____________________________________________________________________ 3. Do any adults (19 or older) for whom you are applying have a mental or physical disability or kidney disorder? If yes, fill out below. Name: Tell us about this persons disability or medical condition. Yes No

Has this disability lasted more than 1 year? Yes No Will this disability last more than 1 year? Yes No If you have applied for disability benefits through the Social Security administration (SSA) for this disability, tell us: Date of your application When did you get a decision letter Your application was: Approved Denied (month, year): (month, year)? If your application was denied, did you appeal? Yes No If yes, what was the appeal date (month, year): ____________________________________________ Has the disability gotten worse since you were denied benefits? Yes No If yes, when did the disability get worse (month/year)? __________________ Tell us how it got worse: Is there a new medical condition since you were denied benefits? Yes No If yes, when did it start (month/year)? _________________________ Tell us about the new condition: *Please make copies of this page for additional people. 4. Oregon has a 60 month time limit for Temporary Assistance for Needy Families (TANF). Months you received TANF in another state may be counted towards the Oregon Time Limit. Yes No Did you or anyone you are applying for get TANF in any state since 1996? If yes, please complete below. State Months on TANF

Person

Agency use only

PWE? Yes No

UC disqualification? Yes No

Presumptive referral? Yes No Incapacity? Yes No

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Tell us about your households medical insurance

Please answer the following questions for anyone in your home (related to you or your child(ren)): 1. Does anyone who is 19 years or older have health insurance now, or did they have it in the last Yes No six months? If yes, who? ___________________________________________________________________ 2. Does anyone who is 18 years or younger have health insurance now, or did they have it in the Yes No last two months? If yes, who? ___________________________________________________________________ 3. Has anyone received medical benefits from another state or through another state agency, such as Yes No Child Welfare, this month or last month? If yes, who? ___________________________________________________________________ 4. Has anyone had 5. Has anyone lost health coverage coverage because through COBRA a parent lost a job, within the last had their hours two months? reduced or it was no longer offered Yes No through work? If yes, who? Yes No If yes, who? 6. Has anyone had coverage in the last two months through Oregon Medical Insurance Pool (OMIP), Family Medical Insurance Pool (FMIP), or Family Health Insurance Assistance Program (FHIAP)? Yes No If yes, who? 7. Has anyone had coverage within the last two months through Kaiser Permanente Child Health Insurance or Kaiser Transition Program? Yes No If yes, who?

If you answered yes to questions 1-7 above, please tell us the date the insurance will end or did end: ________________________________________________________________________

Please provide a copy of the front and back of insurance cards for current coverage or for coverage that has ended in the past two months. 8. Is anyone who is applying for medical benefits able to get private health insurance or Yes insurance through an employer? 9. Is anyone in the military, a veteran or a spouse/dependent of someone who is? 10. Can anyone qualify for Medicare (medical coverage from Social Security)? 11. Does anyone have a past, current or future insurance claim for an injury? Yes Yes Yes No No No No

12. Has anyone been diagnosed with End Stage Renal Disease (ESRD) or received routine dialysis Yes No treatment or has anyone received a kidney transplant within the last 36 months? If yes, who? ____________________________________________________________________ 13. List anyone who is an Alaska Native or a member of a federally recognized American Indian tribe. List anyone who receives services through Indian Health Program services now or could receive services. _________________________________________________________________________ _________________________________________________________________________________

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14. Choosing a plan. There may be a Coordinated Care Organization, or CCO, available in your community. CCOs are local networks of doctors, mental health providers, hospitals and other providers. They work together for patient-centered care for people on the Oregon Health Plan and Healthy Kids. Read more about CCOs at www.health.oregon.gov. We encourage you to choose a CCO and dental plan or a medical and dental plan. If you dont make a choice, we may choose for you. Before you pick, you might want to ask your doctor and dentist which plans they accept. Read the list of plans at www.oregon.gov/dhs/healthplan. Write your first and second choices for CCOs and dental or medical and dental plans below. Sometimes the first choice is full. Depending on which program your children qualify for, we may send you a letter asking you to choose another medical plan. CCO - 1st choice Dental plan - 1st choice CCO - 2nd choice Dental plan - 2nd choice

OR
Medical plan - 1st choice Dental plan - 1st choice Medical plan - 2nd choice Dental plan - 2nd choice

15. American Indians and Alaska Natives who want to be enrolled in plans. American Indians, Alaska Natives and people who have access to care through Indian Health Services may choose to enroll into a Coordinated Care Organization (CCO) or a managed care plan where available. You may also choose to be enrolled in a dental and/or mental health plan only. If you are enrolled in a CCO or a managed care plan, you can still access services at Indian Health Services, the Urban Indian Program or through the Tribal Health Clinic. If American Indian or Alaska Native and you choose to enroll in plans, use the boxes above to write your plan choices. If American Indian or Alaska Native and you choose not to enroll in a plan, use the lines below. List who does not want to be enrolled in a medical plan, dental plan, mental health plan or Coordinated Care Organization: These people do not want to be enrolled in a Medical Plan: Name(s) __________________________________________________________________________ These people do not want to be enrolled in a Dental Plan: Name(s) __________________________________________________________________________ These people do not want to be enrolled in a Mental Health Plan: Name(s) __________________________________________________________________________ These people do not want to be enrolled in a Coordinated Care Organization: Name(s) __________________________________________________________________________ If you dont enroll in a plan, you will be covered by an open card that allows you to get care through Indian Health Services, Tribal Health Clinics and other providers based on your area. You can let your worker know at anytime if you decide you would like to be enrolled into a plan.

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Information about cash and medical benefits

Cash for families is also known as Temporary Assistance for Needy Families or TANF. TANF is intended to meet a familys basic needs such as food, clothing, shelter and utilities. Most TANF benefits in Oregon are issued via an Electronic Benefit Transfer (EBT) card. This is also known as an Oregon Trail Card. TANF benefits may not be used in an EBT transaction or accessed in an EBT transaction in any:

Liquor store; Casino, gambling casino or gaming establishment; Retail business that provides adult entertainment in which performers disrobe or perform in an unclothed state.

If you are applying for cash for families along with medical benefits
Assigning payments To qualify for public assistance, you must let the Oregon Health Authority (OHA) or the Department of Human Services (DHS) have any money you or other recipients of assistance receive or have the right to receive from: Private health insurance; Other people or other sources who are or may be liable to cover costs paid by OHA or DHS related to an injury. If you or the recipient of assistance have a claim against someone else for an injury, such as a car accident, please see page 14, The states right to place a lien on any injury claims. By signing this form, you agree to assign to OHA and DHS all rights to these payments for anyone who is covered by your public assistance. That means yourself and other family members (including any child born in the future). By signing this form, you agree to help DHS and OHA find and obtain these payments. There is a limit on how much DHS and OHA can take in payments. It cannot take more than the amount it has paid in assistance for you and your family. You also agree that medical providers, hospitals, employers and government agencies can release medical records to insurance companies. This covers records about you and other family members on medical assistance. This will only be done for the purpose of getting payment. What you need to know about assigning support Support means money you get for you or your children, like alimony or child support. When you get cash benefits, you are assigning the state the right to keep the support you or anyone in your family get from another person. The money goes to repay the state for the cash you get. NOTE: This does not apply during any period of time that you receive cash benefits from JOBS Plus, the State Family Pre-SSI/SSDI Program (SFPSS), the Post-TANF Program or when you are a two-parent family. This means that while you are getting cash benefits: The state will keep part of the support payments (for both current and past-due payments) received for you and members of your family. The state will not keep all your child support. The state will send you $50 of current child support received per child per month up to $200 per family per month. The state will not count this money as income when figuring your eligibility and benefits.

If you are applying for cash for families:

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NOTE: If you are an applicant for cash assistance or you are in SFPSS or JOBS Plus or you are a two-parent family, the state will generally not keep any of your child support. When determining your eligibility and benefits, $50 (per child per month up to $200 per family per month) of current child support received will not be counted towards your monthly income. When you leave the cash program: Current support payments will go to you; Any past-due payments for months you were on cash assistance will be kept by the state; Any past-due payments for months you were not on cash assistance may go to you. Working with Child Support While you are getting cash benefits, you will need to work with the states Child Support Program. Important: You do not have to work with child support if you think it would mean danger for you or your children. Working with child support can mean: Helping to locate your childs other parent (unless you think it would mean danger for you or your children); Legally naming the childs father (establishing paternity); Getting a support order.

If you are applying for medical benefits:

Oregon Health Plan (OHP) The Oregon Health Plan (OHP) is a state health care coverage program for adults with low incomes. OHP includes medical care, dental care, and mental health and substance abuse treatment. You may have to pay a monthly premium (cost) for your OHP coverage. You may have to pay a copayment for some services you get. For more information about OHP, go to www.oregon.gov/DHS/ healthplan. Healthy Kids

Coverage varies depending on what you qualify for. For example:

Healthy Kids is a program for Oregon children and teens up to age 19. It includes medical, dental, vision, prescription drugs, mental health coverage and substance abuse treatment. Even middle-income families can get no-cost or low-cost coverage. Depending on your income, your family may qualify for Healthy Kids in one of the following ways: No-cost coverage through OHP Plus; Low-cost, private health insurance through Healthy KidsConnect; Premium assistance, where the state helps you pay for insurance that your employer offers. For more information about Healthy Kids, go to www.oregonhealthykids.gov When you get DHS or OHA medical benefits, OHA will pay your medical bills for covered services. During this time, you must let DHS have any money you get from private health insurance or from an injury. See page 11, Assigning payments for details. Also, if you or other recipient of assistance have a claim against someone else for an injury, such as a car accident please see page 14, The states right to place a lien on any injury claims.

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Helping get other medical coverage

You will need to work with DHS and OHA to try and get medical coverage or money for medical care from other sources. This means: For yourself: You must try to get things such as: Health insurance from your employer (DHS and OHA may be able to help you pay for this); Insurance payments because of an injury; Medical coverage from the Veterans Administration. For your children: If the other parent isnt living with you, you may need to work with the states Child Support Program to get health care coverage and medical cash support for the children. Working with child support While you are getting medical benefits you will need to work with the states Child Support Program. NOTE: This does not apply if your children are receiving Childrens Health Insurance Program benefits or Healthy KidsConnect benefits. Important: You do not have to work with child support if you think it would mean danger for you or your children. Working with child support can mean: Helping to locate your childs other parent; Legally naming the childs father (establishing paternity); Getting an order for health care coverage; Getting an order for cash to help with your childs medical expenses. If you are pregnant and you only want state medical coverage for yourself, you do not have to work with child support. What you need to know about assigning support Support means money you get for you or your children, like alimony or child support. It includes cash ordered to help you pay for your childs medical expenses. When you get DHS or OHA medical for your child, you are assigning the state the right to keep the medical cash support anyone in your family gets from another person. The money goes to repay the state for the medical benefits your child gets. This means that while you are getting DHS or OHA medical benefits: The state will keep all medical cash support payments received for you to help pay for your childs medical expenses. This includes current and past-due payments. When your child leaves the medical program: Current support payments will go to you; Any past-due payments for months your child was on medical assistance will be kept by the state; Any past-due payments for months your child was not on medical assistance may go to you.

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If you have other insurance: If you or a member of your family have other medical insurance, tell the provider (doctor, clinic or hospital) before you get care. They must bill the other insurance company before they bill OHA. If OHA pays a medical bill that should have been paid by insurance, DHS and OHA will take action to get its money back. For example: If OHA pays a bill that private insurance should have paid, DHS and OHA will try to get the money back from the insurance company. If OHA pays a medical bill and the provider also gets paid by an insurance company, DHS and OHA will try to get its money back from the provider. If OHA pays a medical bill and an insurance company sends you a check for it, DHS and OHA will try to get its money back from you. The states right to place a lien on any injury claim of you or other assistance recipients. You or other assistance recipients have a responsibility to notify your worker within 10 days of any claim that you or other assistance recipients may have against someone else who injured you or other assistance recipient. The state may place a lien on such claims. The states right to recover benefits from your estate. DHS or OHA may claim money from your estate (as defined in ORS 416.350) after you die if: You got state medical benefits after you reach age 55 (this includes Oregon Health Plan payments made on your behalf to a managed care plan or payments to a Coordinated Care Organization); You got General Assistance benefits at any age, or; You got state medical benefits during your life, and at the time of your death you were permanently institutionalized (as defined in OAR 461-135-0832) for at least 6 months. These claims are meant to recover money the state paid for your medical benefits and services, and General Assistance benefits. DHS or OHA cannot claim more money than it paid in assistance for you and your family members. DHS or OHA cannot claim this money from your estate if any of the following members of your family are still alive: Your spouse; Any natural or adopted child of yours who is under the age of 21 (this does not include step children), or; Any natural or adopted child of yours, of any age, who is blind or disabled (as defined by Social Security criteria). DHS or OHA cannot claim this money from the estate of any other assistance recipient if any of the following members of that individuals family are still alive: The individuals spouse; Any natural or adopted child of the individual who is under the age of 21 (this does not include step children), or; Any natural or adopted child of the individual, of any age, who is blind or disabled (as defined by Social Security criteria). If you or the assistance recipient dies before their spouse, DHS and OHA will wait until their spouse dies before claiming any money. For more information, please see DHS 9093 form. Please note that the laws and rules regarding claims against an estate may change without notice.

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Information about TANF program penalties

If you knowingly do the following to get Temporary Assistance for Needy Families (TANF) you will get a penalty: Give false information about yourself or someone you are applying for; Hide information about yourself or someone you are applying for; Give false information about where you live.

The first time you do any of these things you will not get TANF for 12 months. The second time you will not get TANF for 24 months. The third time you will not be able to get TANF at all. You will also have to pay back all the TANF you were not supposed to get. Your food benefits will not go up even though you get less in TANF if you told us something that was not true or did not tell us something that was true.

Information about Supplemental Nutrition Assistance Program (SNAP) penalties

If you do the following... Hide information or make false statements Use Electronic Benefits Transfer (EBT) cards that belong to someone else Use food benefits to buy alcohol or tobacco Trade or sell benefits or EBT cards Trade food benefits for controlled substances such as drugs Trade food benefits for firearms, ammunition or explosives Trade, buy or sell food benefits of $500 or more Give false information about who you are and where you live so you can get extra food benefits You will lose food benefits... 12 months for the first offense 24 months for the second offense Permanently for the third offense 24 months for the first offense Permanently for the second offense Permanently Permanently 10 years for each offense

You can also be fined up to $250,000 or put in prison for up to 20 years or both, for doing these things. You may also be charged under other federal laws. If you knowingly do the following... Use EBT cards that are not yours Transfer your EBT cards to other people Acquire or possess EBT cards that are not yours You may be... Guilty of a felony or misdemeanor Fined Put in prison Ineligible for food benefits for a period of time

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Information about all programs Our non discrimination policy

The Department of Human Services (DHS) and the Oregon Health Authority (OHA) do not discriminate against anyone. This means that DHS|OHA will help all who qualify and will not treat anyone differently because of age, race, color, national origin, gender, religion, political beliefs1, disability or sexual orientation2. You may file a complaint if you believe DHS or OHA treated you differently for any of these reasons. To file a complaint with the state, you can call the Governors Advocacy Office at 1-800-442-5238 (TTY 711) or write to their office at: Governors Advocacy Office 500 Summer Street NE, E17 Salem, OR 97301 Fax: 503-378-6532 Email: DHS.info@state.or.us Equal opportunity is the law! The United States Department of Agriculture (USDA) and the United States Health and Human Services (HHS) are equal opportunity providers and employers. Auxiliary aids and services are available upon request to individuals with disabilities. To file a complaint with USDA and HHS, please read the Client Discrimination Complaint Information form (DHS 9001). You can find this form in the Information and Referral Packet (DHS 6609).

Why we need your Social Security number

Social Security numbers (SSN) Federal laws (42 USC 1320b-7(a) and (b), 7 USC 2011-2036, 42 CFR 435.910, 42 CFR 435.920 and 42 CFR 457.340(b)) and DHS rule (OAR 461-120-0210) require anyone applying for cash, food or medical benefits to give DHS or OHA their SSN. This requirement does not apply to anyone only applying for emergency medical benefits through the Citizen/Alien Waived Emergent Medical program or for anyone who is not applying for benefits. a. DHS and OHA will use your SSN to help decide if you are eligible for benefits. Your SSN will be used to verify your income, other assets and to match with other state and federal records such as IRS, Medicaid, child support, Social Security and Unemployment benefits. b. DHS and OHA may use your SSN to prepare aggregate information or reports requested by funding sources for the program you apply for or receive benefits from. c. DHS and OHA may use or disclose your SSN: If it is needed to operate the program you apply for or receive benefits from; To conduct quality assessment and improvement activities; To verify the correct amount of payments and recover overpaid benefits; To make sure nobody gets benefits in more than one household.
1SNAP clients are protected against political belief discrimination. 2Sexual orientation is protected by the State of Oregon, but not federal

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Information about your rights and responsibilities By signing below I agree that:
I have given DHS|OHA true, correct and complete information; I understand that making false statements or hiding information may mean state and federal penalties, as well as having to repay any overpayment (this includes authorized representatives for medical and cash benefits); DHS|OHA can review my case. This could include coming to my home; I declare I am a resident of Oregon; I will report changes in information I give DHS or OHA when DHS or OHA requires me to; I have given true citizenship information about myself and the others I am applying for; I know that DHS or OHA will check the immigration status of people who apply for or get benefits. I know the information DHS or OHA gets from the United States Citizenship and Immigration Service (USCIS) could affect who gets benefits. DHS|OHA will not contact USCIS for anyone not seeking benefits; I authorize release of my child support records from the Department of Justice (DOJ), Division of Child Support (DCS) to DHS or OHA; The adults under age 60 on this form who apply for food benefits (SNAP) will register for the states employment program. If I add people to the program in the future, they will also register; If I do not give DHS or OHA the Social Security number for someone who wants benefits, that person may not be able to get them; DHS will not use costs for shelter, medical, child care and court ordered child support to figure my benefits if I do not report them; DHS or OHA may use computers to check all the information on this form. This includes matching with bank, income and unemployment-benefit records; I understand that DHS or OHA may use or disclose my SSN and the SSN of each person I apply for, for the purposes listed on page 16; DHS or OHA may give the information on this application to: Federal and state agencies who are doing reviews; Law-enforcement officials, to help them arrest someone who is fleeing from the law; Federal and state agencies and private collection agencies, if I have to repay benefits to DHS or OHA I understand DHS may monitor where I use TANF cash benefits through my Oregon Trail Card or withdraw TANF cash benefits using my Oregon Trail Card. I also understand that I may not use my Oregon Trail Card to spend TANF cash benefits or withdraw TANF cash benefits at any: Liquor store. Casino, gambling casino or gaming establishment. Retail business that provides adult entertainment in which performers disrobe or perform in an unclothed state.

Please continue to page 18, read and sign.

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 People applying for cash benefits. I am giving the state the right to keep support payments, as explained on pages 11 14. I understand I do not have to work with the child support program if it would mean danger for me or my children. People applying for medical benefits. I understand the information about medical benefits on pages 11 14. I am giving the state the right to keep support payments as explained on pages 11 14. I agree to turn over my rights to any health insurance payments, starting today. If I have an accident or injury, I assign any rights to support and payment of medical care to DHS|OHA. I will cooperate in identifying and providing information to assist DHS|OHA in pursuing anyone who may be liable to pay for my care, unless I have good cause. This is so OHA can get repaid for paying my health care bills. This agreement is for myself and anyone I apply for. People applying for cash, child care, food and medical benefits. I understand the person who signs this form must repay benefits to DHS|OHA when there is an overpayment in my case. The adults in the SNAP household during the time of overpayment must also repay. People applying for cash and food benefits. I understand I cannot get food benefits from the Tribal Food Distribution program and the SNAP program at the same time. I also cannot get Tribal TANF from a tribe and TANF cash benefits from DHS at the same time. I state under penalty for making a false statement that the statements made about persons in my home, including statements about citizenship, income, resources, property and all other information I have given DHS and their contractors are true and correct. I will give proof of the information I have given DHS. I will also let DHS contact other people and agencies to get proof.

Declaration and signature

I have read and understand my rights and responsibilities as explained above and in the DHS 0415R form, and I have a copy of the form.

Full legal signature of applicant/authorized representative Full legal signature of other parent, spouse or other adult

Date Date Date

Staff witness signature

What is the best way for us to contact you? Phone: _________________________________________________________________________ Email: _________________________________________________________________________ Other: _________________________________________________________________________ What days and times are best for us to contact you? ________________________________________

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