Before signing this document, please read the rights and responsibilities outlined below. If there is anything you do not understand or have questions about, please ask for clarification
If I am a third party applying on behalf of another person, as evidenced by a completed Designation
of Authorized Representative form, my signature below indicates that this application has been examined by
or read to the applicant and, to the best of my knowledge, the facts are true and complete. I understand as
a third party I may be criminally punished for knowingly providing false information.
I understand that any information I give is subject to verification by the New Jersey Department of Human Services,
Division of Medical Assistance and Health Services (DMAHS) for the Medicaid/NJ FamilyCare program, which is called
“NJ FamilyCare” in this application. I understand that my medical benefits may be reduced, denied, or
stopped because of information received through this verification.
I understand that my situation is subject to verification from employers, financial sources and other third parties.
I hereby give permission to NJ FamilyCare to contact any individual or other source that may have knowledge about my
circumstances, or the circumstances of a person necessary for this application, for the purpose of verifying the
statements I have made. I give third parties permission to share information about me with authorized State, State
contractor, and county staff conducting investigations. Third parties include, but are not limited to, financial
institutions, credit reporting agencies, landlords, public housing agencies, schools, utility companies,
insurance agencies, employers, other governmental agencies and others as necessary. I further authorize
taxing authorities to release my tax information and copies of my tax returns.
I understand that the DMAHS eligibility determining agencies and government contractors may exchange
information relating to coverage to assist with this application, enrollment, administration,
and billing services.
I understand that DMAHS has the authority to file a claim and lien against the estate of a deceased
Medicaid beneficiary, or former beneficiary, to recover all NJ FamilyCare payments made on the beneficiary’s behalf
to pay for health care coverage on or after age 55, regardless of whether services were received. A NJ FamilyCare
beneficiary’s estate may be required to pay back DMAHS for those benefits. This includes monthly payments to, for example,
a managed care entity to secure health coverage that you may not use in any month. Visit Estate Recovery - What You Should Know. for more information.
I agree to tell the eligibility determining agency immediately of changes to information entered on this application, including but not limited to the following:
If anyone receiving health benefits moves out of state;
Changes in where we live, get our mail, or any other contact information;
Changes in other health insurance coverage;
Changes in income and/or resources;
Improvement in medical condition, if disabled;
Marriage, divorce, or death of spouse;
Addition or loss of household member, including pregnancy;
Sale or transfer of my home or other property;
Lawsuits and inheritances.
I understand that failure to report changes in application information,
including those changes listed above, may result in incorrectly paid benefits/coverage
and I may have to reimburse the State of New Jersey for those benefits/coverage.
I understand that the outcome of this application may be shared with any provider who provided services to the applicant/beneficiary during the period covered by the application.
I understand, as a condition of being covered under Medicaid/NJ FamilyCare, that I have assigned to the Commissioner
of the Department of Human Services, any rights to support for the purpose of medical care as determined by a court or
administrative order and any rights to payment for medical care from any third party including but not limited to other health insurance,
legal settlements, or other third parties. I agree to release any medical information needed by the NJ FamilyCare program or others for
the purpose of paying or receiving payment of medical bills. I agree to help in obtaining medical support and payments from anyone who
is legally responsible.
I understand that I may request a fair hearing if I am not satisfied with the determination taken regarding my application.
I may be eligible for retroactive NJ FamilyCare coverage for unpaid covered medical services by Medicaid Fee-for-Service providers during
the three (3) months prior to this application. I further understand that these retroactive benefits will only apply to the month(s)
that eligibility requirements are met.
I understand that an individual is only permitted to retain $2,000 or $4,000 in resources, depending on the program.
I understand that if I am seeking Long Term Services and Supports or services based on an institutional level of care,
NJ FamilyCare will examine transfers of resources that occurred within the look back period before, and any time after,
my first date of applying for benefits.
In order to redetermine my eligibility for NJ FamilyCare in the future, I agree to allow NJ FamilyCare to use income data, including
tax information. At time of renewal, NJ FamilyCare will send me a renewal notice and let me indicate any changes in my or my household’s
eligibility information, and I can withdraw my request for benefits in writing at any time.
I understand that if some or all of the individuals applying do not qualify for NJ FamilyCare health coverage, that they may be
eligible for federal benefits and/or may explore private health coverage options through the Federal Health Insurance Marketplace (Marketplace).
If this is the case, I authorize NJ FamilyCare and its contractors to give information contained in this application to the Marketplace.
I understand that the NJ FamilyCare program may use or disclose protected health information about me or my children if State or
Federal privacy laws require or allow it.
I authorize my employer to release health benefits information to the NJ FamilyCare Office of Premium Support.
I will obey the law and regulations of the program.
I know that under federal law, discrimination is not permitted on the basis of race, color, national origin, sex, age, or disability.
I can get more information, including how to file a complaint of discrimination by reading the NJ FamilyCare Non-Discrimination Statement.
I authorize any educational institution or school district to release my medical records or those of my child(ren) to the
NJ FamilyCare program for the purpose of determining eligibility and billing the Program.
If found eligible for NJ FamilyCare, I know I will be asked to cooperate with the agency that collects medical
support from an absent parent. If I think that cooperating to collect medical support will harm me or my children,
I can tell NJ FamilyCare and I may not have to cooperate.
NOTE: The submission of a Social Security number (SSN) is mandatory in accordance with 42 U.S.C.1320b-7.
The SSNs provided (including for a husband or wife, family members, or dependents) will be used to associate records
pertaining to applicants and other persons necessary for the determination of eligibility, to verify identity, to verify income,
to check other financial records such as bank account information, to the extent it is useful in verifying eligibility or the
amount of medical assistance payments under 42 CFR 435.940 through 435.960, and preventing duplicate participation or
incorrectly paid benefits for you and for persons in your household. The SSNs will be used in computer matching and
program reviews or audits. These procedures are designed to determine eligibility and to identify persons who fraudulently
or wrongfully participate in Medicaid and DMAHS programs. Such persons may be subjected to criminal action, administrative claims,
and/or possible loss of all benefits. Failure to file for a SSN may result in disqualification for Medicaid.
NJ FamilyCare complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national
origin, sex, age or disability. If you speak any other language, language assistance services are available at no cost to you.
Call 1-800-701-0710 (TTY: 1-800-701-0720).