APPENDIX D Flint Water Group By completing these questions, you are requesting enhanced Medicaid coverage for individuals due to potential exposure to lead in the city of Flint water system. Answer the questions below for anyone who is currently under age 21, pregnant, or pregnant within the last 2 months. Please list anyone who consumed from the Flint water system and lived, worked, or received childcare or education at an address that was served by the Flint water system at any time from April 2014 through the present. Between April 2014 and present day, did any applicant live at an address that was served by the Flint water system? Please include all addresses and indicate all applicants who lived at each address. Address served by the Flint water Names of applicants who lived at the address Dates applicants lived at the system address (From/To) Between April 2014 and present day, did any applicant work at an address that was served by the Flint water system? Please include all addresses and indicate all applicants who worked at each address. Address served by the Flint water Names of applicants who worked at the address Dates applicants worked at the system address (From/To) Between April 2014 and present day, did any applicant attend school or receive childcare at an address that was served by the Flint water system? Please include all addresses and indicate all applicants who attended school or received childcare at each address. Address served by the Flint water Names of applicants who attended school/childcare at the Dates applicants attended system address school/childcare at the address (From/To) You may be asked to provide verification or proof that you consumed water and lived, worked or received regular services (attend childcare or school) at an address that was served by the Flint water system from April 2014 through present day. Any knowingly false information or statements provided may be reviewed by the Office of Inspector General.
APPENDIX D Flint Water Group By completing these questions, you are requesting enhanced Medicaid coverage for individuals due to potential exposure to lead in the city of Flint water system. Answer the questions below for anyone who is currently under age 21, pregnant, or pregnant within the last 2 months. Please list anyone who consumed from the Flint water system and lived, worked, or received childcare or education at an address that was served by the Flint water system at any time from April 2014 through the present. Between April 2014 and present day, did any applicant live at an address that was served by the Flint water system? Please include all addresses and indicate all applicants who lived at each address. Address served by the Flint water system Names of applicants who lived at the address Dates applicants lived at the address (From/To) Between April 2014 and present day, did any applicant work at an address that was served by the Flint water system? Please include all addresses and indicate all applicants who worked at each address. Address served by the Flint water system Names of applicants who worked at the address Dates applicants worked at the address (From/To) Between April 2014 and present day, did any applicant attend school or receive childcare at an address that was served by the Flint water system? Please include all addresses and indicate all applicants who attended school or received childcare at each address. Address served by the Flint water system Names of applicants who attended school/childcare at the address Dates applicants attended school/childcare at the address (From/To) You may be asked to provide verification or proof that you consumed water and lived, worked or received regular services (attend childcare or school) at an address that was served by the Flint water system from April 2014 through present day. Any knowingly false information or statements provided may be reviewed by the Office of Inspector General.
DCH-1426-Application_for_Health_Coverage__Help_Paying_Costs_with_Appendix_A-B-C_452145_7.docx