The Florida DH 3212 form is a Health Insurance Application for Extended Family Planning Benefits, specifically designed for individuals seeking Medicaid support for family planning services. This application helps determine eligibility for the Medicaid Family Planning Waiver program, which provides essential benefits to those who qualify. For assistance in filling out the form, please click the button below.
The Florida DH 3212 form serves as a crucial tool for individuals seeking access to extended family planning benefits through a special Medicaid program. This application is designed for those who have lost their full Medicaid coverage and are in need of family planning services. It requires applicants to provide personal information, including their name, contact details, and residence, which is essential for processing. In addition to basic identification, the form prompts applicants to disclose their reproductive history, specifically regarding any previous surgeries such as hysterectomies or tubal ligations. Furthermore, it assesses the applicant's household composition, requiring details about all individuals living in the home, along with their respective income sources. This information is vital for determining eligibility based on income thresholds, which must not exceed 185% of the current federal poverty level. The form also addresses health insurance coverage and participation in KidCare programs, ensuring that applicants are fully informed about their options. It concludes with a certification section, where applicants affirm the accuracy of their information and consent to the sharing of necessary medical and financial data for eligibility verification. By completing the DH 3212, individuals take an important step toward accessing essential family planning services, thereby empowering themselves to make informed choices about their reproductive health.
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.
Relationship to
**Social Security
Date of Birth
Race
Sex
US Citizen?
** If no, give INS
Date of
Applied for
Applicant
Yes
No
ID Number
Entry
Medicaid?
(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:
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: _________________________________
7.
If you are 18 or under, are you enrolled in any KidCare program? Yes No
8.
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
(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
Filling out the Florida DH 3212 form is a crucial step in applying for extended family planning benefits. After completing this form, it will be submitted to your local county health department for processing. Ensure that all information is accurate and complete to avoid delays in your application.
What is the Florida DH 3212 form?
The Florida DH 3212 form is an application for the Health Insurance Application for Extended Family Planning Benefits. This special Medicaid program is designed to assist individuals who need family planning services but have lost their full Medicaid coverage. It helps determine eligibility for these benefits based on various factors, including income and reproductive history.
Who is eligible to apply for the DH 3212 form?
To be eligible for the Medicaid Family Planning Waiver program, applicants must meet several criteria. They should not have had a hysterectomy or tubal ligation, must not be currently pregnant, and should desire family planning services. Additionally, their income must be less than or equal to 185% of the current federal poverty level.
What information do I need to provide on the form?
The form requires personal information such as your name, address, and contact details. You will also need to provide information about your reproductive history, household members, income sources, and health insurance status. Specifically, only the applicant must provide their Social Security number and proof of citizenship and identity.
How do I submit the DH 3212 form?
You can submit the completed DH 3212 form by mailing it or bringing it in person to your local county health department. It’s important to note that you should not send this application directly to Medicaid.
What happens after I submit my application?
Once your application is received, the health department will review the information provided to determine your eligibility for the program. You may be contacted by phone if additional information is needed. Additionally, you will receive a notification by mail regarding your eligibility status.
What should I do if I don’t have all the required information?
If you do not have all the required information, it is advisable to gather as much as you can before submitting the form. Incomplete applications can delay the determination process. If you are unsure about certain details, consider reaching out to your local health department for guidance.
Is there a deadline for submitting the DH 3212 form?
There is no specific deadline mentioned for submitting the DH 3212 form; however, it is best to apply as soon as you determine that you are eligible. Prompt submission can help ensure that you receive benefits without unnecessary delays.
What should I do if my application is denied?
If your application is denied, you will receive a notification explaining the reasons for the denial. You have the right to appeal this decision. The notification will provide information on how to proceed with the appeal process, including any deadlines you need to meet.
What documents do I need to attach to the application?
Along with the DH 3212 form, you must attach proof of U.S. citizenship and identity. Acceptable documents include a U.S. Passport, a U.S. Birth Certificate, or other certified copies of citizenship documents. Ensure that you provide originals or certified copies, as photocopies are not acceptable.
Filling out the Florida DH 3212 form can be straightforward, but many make common mistakes that can delay their application. One frequent error is not providing complete contact information. Ensure that both your residence and mailing addresses are filled out accurately. If you have a different mailing address, include it. This information is crucial for communication regarding your eligibility.
Another common mistake is failing to answer all questions thoroughly. Questions 1 through 3 ask about your reproductive history and your desire for family planning services. Omitting answers or marking “No” without explanation can lead to misunderstandings about your eligibility. It’s essential to provide clear and complete responses.
Many applicants also overlook the requirement to list everyone living in their household. Question 4 specifically asks for this information, and it is important to include all individuals, starting with yourself. Missing names or relationships can create confusion and delay the processing of your application.
Providing inaccurate or incomplete income information is another mistake. In Question 5, you must include the income sources and gross income for everyone in your home. Be specific about how often you receive this income. Incomplete or incorrect data can lead to a denial of benefits.
Health insurance details are crucial, yet some applicants skip Question 6. If you have health insurance, you must provide the name of the insurance company. Not answering this question can raise concerns about your eligibility for the program.
Additionally, many people forget to attach proof of U.S. citizenship and identity, as required in Question 9. Acceptable documents include a U.S. Passport or Birth Certificate. Only originals or certified copies are valid. Failing to include this documentation can result in immediate rejection of your application.
Another mistake is not signing and dating the form. The Certification and Authorization section is critical. Your signature confirms that the information provided is accurate. Forgetting to sign or dating it incorrectly can lead to processing delays.
Lastly, some applicants mistakenly send their completed forms to Medicaid instead of their local county health department. Ensure you mail or deliver the application to the correct location to avoid unnecessary delays in processing your application.
The Florida DH 3212 form is essential for individuals seeking extended family planning benefits under Medicaid. This application is often accompanied by several other important documents that help establish eligibility and provide necessary information to the Department of Health. Below is a list of commonly used forms and documents that complement the DH 3212 form.
Gathering these documents is crucial for a smooth application process. Each document plays a significant role in determining eligibility for the Family Planning Waiver Program, ensuring that applicants receive the benefits they need. It is advisable to review all requirements carefully before submission to avoid any delays in processing.
When filling out the Florida DH 3212 form, there are important dos and don'ts to keep in mind. Follow these guidelines to ensure your application is processed smoothly.
Misconceptions about the Florida DH 3212 form can lead to confusion and hinder access to essential family planning services. Below are eight common misconceptions, along with clarifications to promote understanding.
Understanding these misconceptions can empower individuals to seek the family planning services they need without unnecessary barriers. It is important to approach the application process with accurate information to ensure a smoother experience.
When it comes to applying for the Florida DH 3212 form, understanding the nuances can make a significant difference in the process. Here are some essential takeaways to keep in mind:
By keeping these key points in mind, you can navigate the application process more smoothly and increase your chances of receiving the necessary benefits for family planning services.