222.23 Family Planning MA Required Verification SR 13-30, 07/13 (FAM-A)

The individual who signs DFA Form 800FP, Application for Family Planning Medical Assistance, must provide verification of all eligibility criteria:

• NH residency. See Section 303.05, How to Verify Residence;

• identity. See Section 301.07, Verification of Identity;

• enumeration status. See Section 309.07, Verification;

• alien or citizenship status. See PART 305, Citizenship;

• all income, including the most recent 4 weeks of earned income. See PART 500, INCOME;

• health insurance, if already covered. This can be a copy of the front and back of the insurance card as long as it contains the following information, or the following information: Name of insurance company, Policy and Group Number, Name of Policy Holder, date the insurance began and the date it ends, if known; and

• if the family claims deductions, the deductions must be verified, otherwise no amount is deducted from income. See Section 222.09, Family Planning MA Allowable Deductions.