Florida Forms
Homepage ↦ Florida Dh 3212 Form in PDF
Content Navigation

Understanding the Florida DH 3212 form is essential for those seeking extended family planning benefits through Medicaid. This application serves as a gateway to a special Medicaid program designed to assist individuals in managing their reproductive health. The form collects vital information, including personal details such as name, address, and contact numbers, as well as specific questions about reproductive history, income sources, and health insurance coverage. Applicants must provide their Social Security number and proof of citizenship, which can include documents like a U.S. passport or birth certificate. The form also inquires about household members and their income, ensuring that eligibility can be accurately determined based on federal poverty guidelines. By signing the application, individuals consent to the sharing of their medical and financial information for the purpose of eligibility assessment, underscoring the importance of transparency in the process. Completing the DH 3212 accurately and thoroughly is crucial, as any omissions can delay the determination of benefits, making it vital for applicants to pay close attention to the instructions provided.

Form 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

No

ID Number

Entry

Medicaid?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Yes

No

 

 

 

 

 

(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: _________________________________

 

 

 

 

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

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

⇩ Florida Dh 3212 File

Document Breakdown

Fact Name Details
Form Purpose The Florida DH 3212 form is an application for the Health Insurance Application for Extended Family Planning Benefits under Medicaid.
Eligibility Criteria Applicants must not have had a hysterectomy or tubal ligation, must not be pregnant, and must have an income at or below 185% of the federal poverty level.
Required Documentation Applicants must provide proof of U.S. citizenship and identity, such as a U.S. Passport or Birth Certificate, along with their Social Security Number.
Governing Law This form is governed by Florida Medicaid regulations and policies regarding family planning services.
Please rate Florida Dh 3212 Form in PDF Form
4.63
Incredible
19 Votes

Popular PDF Forms

Sales Tax License Florida - Highlights the importance of reading instructions for each line, ensuring that businesses can accurately fulfill their tax obligations.

Contract to Lease Florida - Mandates that changes or additions to the form should only be made with legal guidance, ensuring any alterations are legally sound.

Joint Custody in Florida Form - A final judgment form is included, which the judge will complete based on the case's outcome.