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Overview

The Florida DH 3212 form, a pivotal document issued by the Department of Health, serves as an application for the Medicaid Family Planning Waiver program. It's designed to extend family planning benefits to individuals who have lost their full Medicaid coverage but meet certain eligibility criteria, emphasizing the need for accessible family planning services. Applicants are required to disclose personal details, including reproductive history and desires for future family planning, to assess their eligibility for this special program. The form requires information such as name, residence, contact details, income sources of all household members, and existing health insurance status, intending to capture a comprehensive snapshot of the applicant’s current situation. Additionally, it mandates the provision of evidence for U.S. citizenship and income verification for a thorough assessment. Signing the form indicates the applicant’s consent for the Department of Health to access and release their confidential medical and financial information to facilitate the eligibility determination process and coordination of care. Importantly, the form underscores the confidentiality of the shared information, in compliance with Florida and federal laws, while also detailing the applicant’s rights and responsibilities within the program.

Example - Florida Dh 3212 Form

 

 

 

 

 

 

 

 

 

 

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 PDF

File Specifications

Fact Name Description
Form Purpose The Florida DH 3212 form is designed for individuals seeking to apply for extended family planning benefits under a special Medicaid program.
Eligibility Criteria Applicants are eligible if they have lost full Medicaid coverage, have not undergone a hysterectomy or tubal ligation, are not pregnant, desire family planning services, and have an income less than or equal to 185% of the federal poverty level.
Required Information Applicants must provide detailed personal, contact, reproductive history, household, and income information, including social security number and proof of citizenship for the applicant, and income details for other household members.
Health Insurance Inquiry The form inquires whether the applicant currently has health insurance and, if applicable, whether their insurance includes family planning as a benefit.
Document Submission Applicants must attach proof of U.S. citizenship and identity, and if employed, provide proof of income via recent pay stubs.
Authorization Section By signing the form, applicants authorize the Department of Health to obtain and release their confidential financial and medical information to determine eligibility and coordinate care within the Family Planning Waiver Program.
Governing Law The process and privacy protections related to the DH 3212 form are governed by both Florida and federal laws, ensuring confidential handling of applicant information.

Instructions on Filling in Florida Dh 3212

The process of applying for the Health Insurance Application for Extended Family Planning Benefits in Florida is critical for individuals seeking support through the Medicaid Family Planning Waiver program. This step-by-step guide will walk you through filling out the Florida DH 3212 form in a clear, straightforward manner. Starting with personal information and moving through questions about your reproductive history, insurance status, and household income, each section must be completed with accurate information. The authorization at the end of the application is essential for processing, as it allows the Department of Health to obtain and release your confidential information to determine eligibility. Here's how to properly fill out the form:

  1. At the top of the form, enter the date you are filling out the application under "Office Date Received."
  2. Fill in your full legal name (first, middle initial, and last) and if applicable, your maiden name.
  3. Provide your area code and phone number. If you do not have a home phone, include a number where you can be reliably reached.
  4. Enter your residence address, including apartment number if applicable, then your city, county, state, and zip code. If your mailing address is different, include that in the space provided.
  5. Respond to the questions about your reproductive history (hysterectomy and tubal ligation) and your last menstrual period.
  6. Indicate if you wish to receive family planning services through this program.
  7. List all people living in your home, starting with yourself. You'll need to include their names, relationships to you, their social security numbers (if applicable), date of birth, race, sex, citizenship status, and INS ID numbers if they are not U.S. citizens.
  8. For question 5, document the income of everyone in your household. This includes types of income, gross income before deductions, and frequency of payment. Also fill in current job information and child care costs for job purposes.
  9. Answer whether you currently have health insurance, and if so, provide the name of your insurance company.
  10. If under 18, indicate whether you are enrolled in any KidCare program and if your insurance includes family planning as a benefit.
  11. Attach proof of US citizenship and identity as listed on the form. Only original documents or certified copies will be accepted.
  12. Read the Certification and Authorization section carefully. By signing, you agree to let the Department of Health release and obtain your confidential financial and medical information to assess eligibility.
  13. Sign and date the form. There must also be a signature and date from Eligibility Staff. Note the termination date provided by FMMIS if available.
  14. Finally, mail or bring the completed application to your local county health department. Do not send this form to Medicaid directly.

After submitting the form, your eligibility for the program will be assessed based on the information provided. It's important to ensure all information is complete and accurate to avoid any delays in the determination process. If successful, you will be contacted with further instructions or information regarding your participation in the Family Planning Waiver program.

Understanding Florida Dh 3212

What is the Florida DH 3212 form?

The Florida DH 3212 form is a health insurance application for Extended Family Planning Benefits, which is part of a special Medicaid program. It's designed to provide eligible individuals with family planning services to delay pregnancy. The form collects personal information, reproductive history, income details, and insurance status to determine eligibility for the program.

Who is eligible for the Extended Family Planning Benefits program?

Eligibility for the Extended Family Planning Benefits program is primarily for those who have lost full Medicaid coverage, have not undergone a hysterectomy or tubal ligation, are not currently pregnant, desire family planning services, and have an income less than or equal to 185% of the current federal poverty level.

What information do I need to provide on the DH 3212 form?

When filling out the DH 3212 form, you'll need to provide your name, contact information, reproductive history, details about the people living in your home, your income information, and whether you currently have health insurance. Additionally, the applicant must provide their Social Security Number, proof of U.S. citizenship and identity if applicable, and proof of income such as recent pay stubs.

Do I need to provide proof of U.S. citizenship?

Yes, proof of U.S. citizenship and identity is required when applying for the Extended Family Planning Benefits program using the DH 3212 form. Acceptable documents include a U.S. passport, U.S. birth certificate, or other specified certificates. Only originals or certified copies are acceptable as proof.

How is my income information used in determining eligibility for the program?

Your income information is used to ensure that your earnings do not exceed 185% of the federal poverty level, which is a key eligibility criterion for the Extended Family Planning Benefits program. You'll need to provide details about the income of everyone living in your household to accurately assess your financial situation.

Can I apply for this program if I already have health insurance?

Yes, you can still apply for the Extended Family Planning Benefits program if you have existing health insurance. However, you'll need to disclose this information on the DH 3212 form and indicate whether your insurance includes family planning as a benefit. This information helps determine how the program can best supplement your existing coverage.

What happens after I submit the DH 3212 form?

After submitting the DH 3212 form to your local county health department, your application will be reviewed to determine your eligibility for the Extended Family Planning Benefits program. You will be contacted by phone or mail with additional questions or to inform you about your eligibility status. It's important to ensure all contact information is accurate to avoid delays in processing your application.

Common mistakes

When filling out the Florida DH 3212 form, a Health Insurance Application for Extended Family Planning Benefits, it is important to avoid common mistakes to ensure the application process is as smooth as possible. Below are eight common errors to watch out for:

  1. Not completing the contact information section in full, including both residence and mailing addresses if they are different. This can delay the processing of the application.

  2. Failing to answer questions 1-3 which relate to reproductive history and the desire to participate in the Family Planning Waiver program. These are crucial for determining eligibility.

  3. Forgetting to list all the people living in the household in question 4, including their relation to the applicant and required details for only the applicant such as Social Security Number and proof of U.S. Citizenship, if applicable.

  4. Omitting income information in question 5, which asks for details about any source of income for anyone living in the home, including jobs, child support, or other contributions. Accurate income information is vital for eligibility consideration.

  5. Leaving questions 6-8 about insurance information blank. Whether or not the applicant has health insurance, including if it covers family planning as a benefit, impacts eligibility and the types of benefits received.

  6. Not attaching proof of U.S. citizenship and identity, as requested in question 9. Only originals or certified copies are acceptable, and failure to provide these can delay eligibility determination.

  7. Signing and dating the form incorrectly or not at all in the certification and authorization section. This form is legal documentation that requires the applicant’s and eligibility staff’s signatures to process.

  8. Sending the application to Medicaid or the wrong address instead of the local county health department. The proper submission method and address are critical for the application to reach the correct office for processing.

To avoid these mistakes, it is advised to review the application thoroughly before submission, ensuring that all requested information is provided accurately and in full. This helps in quick and efficient processing, moving one step closer to receiving benefits.

Documents used along the form

The Florida DH 3212 form is an essential document for those seeking extended family planning benefits under a Special Medicaid Program. To complete the application process efficiently and ensure eligibility for the Medicaid Family Planning Waiver program, applicants are often required to provide additional forms and documentation alongside the main form. Understanding these additional documents is crucial for a smooth application process.

  • Proof of U.S. Citizenship and Identity: Applicants must attach proof of U.S. citizenship and identity, such as a U.S. Passport, U.S. Birth Certificate, or Form FS-240 (Report of Birth Abroad of a Citizen of the U.S.). These documents confirm the applicant's citizenship status and are mandatory for processing the application.
  • Proof of Income: Pay stubs from the last four weeks or other official documents that verify income are required. This proof is necessary to determine the financial eligibility of the applicant for the Medicaid Family Planning Waiver program, ensuring their income aligns with program guidelines.
  • Proof of Insurance: If an applicant indicates they have health insurance, documentation or an insurance card must be provided. This information helps determine how the Medicaid Family Planning Waiver program can best supplement the applicant's existing coverage.
  • KidCare Program Documentation: For applicants under 18, proof of enrollment in any KidCare program is necessary if they answered yes to being enrolled. This establishes the applicant's current coverage and benefits eligibility.

Accurately completing the DH 3212 form and attaching all relevant documents ensures applicants receive the benefits they need without unnecessary delay. Each piece of documentation plays a vital role in verifying eligibility and facilitating the efficient coordination of care under the program. Applicants are encouraged to review their submissions carefully and ensure that all information is complete and accurate to support their application.

Similar forms

The Florida DH 3212 form is a health insurance application for extended family planning benefits, falling within a subset of Medicaid programs designed towards specific health needs. Other documents, while varying in scope and purpose, also serve to facilitate access to healthcare or government assistance, reflecting similar underlying objectives. Below are 10 documents demonstrating similarities in purpose or process:

  • Medicaid Application: Similar in its purpose to facilitate access to Medicaid, a government assistance program providing health coverage to low-income individuals and families.
  • CHIP Application (Children's Health Insurance Program): Shares objectives with the Florida DH 3212 form by offering health coverage to children in families that earn too much to qualify for Medicaid but cannot afford private insurance.
  • Marketplace Insurance Application: Both applications require information about income, household size, and resident status to determine eligibility for health insurance plans, with subsidies available based on the applicant's financial situation.
  • WIC Application (Women, Infants, and Children): Like the DH 3212 form, it targets a specific segment of the population — pregnant women, breastfeeding mothers, and children under 5 — offering nutritional assistance and support, incorporating health into the qualification process.
  • SNAP Benefits Application (Supplemental Nutrition Assistance Program): While focusing on food assistance, the SNAP application gathers similar information regarding household composition, income, and need, reflecting a process aimed at evaluating eligibility for government support.
  • Temporary Assistance for Needy Families (TANF) Application: This document provides financial assistance to families, similar to the DH 3212 form's healthcare assistance, both requiring detailed household and income information for eligibility determination.
  • Section 8 Housing Assistance Application: While focused on housing rather than healthcare, this application parallels in collecting personal information, financial status, and family size to establish qualification for aid.
  • SSI Application (Supplemental Security Income): Aims at providing financial assistance to aged, blind, or disabled people, collecting detailed information on health, financial status, and living arrangements, akin to the DH 3212 form's processes.
  • VA Health Benefits Application: For veterans seeking healthcare services through the Department of Veterans Affairs, requiring submission of personal, health, and military service information to establish eligibility, drawing parallels in healthcare access facilitation.
  • Disability Insurance Benefits Application: Similar to the DH 3212 form in its healthcare context, this document is for individuals who are unable to work due to disability, necessitating detailed health and personal information for eligibility.

These documents, while serving various aspects of health and welfare assistance, share a commonality with the Florida DH 3212 form in their aim to evaluate and determine eligibility for specific benefits, utilizing personal, financial, and sometimes health-related information to facilitate access to necessary services.

Dos and Don'ts

When filling out the Florida DH 3212 form, it's crucial to pay close attention to the details required to ensure a smooth process. Here are five things you should do:

  • Ensure all personal information is filled out accurately, including your Name, Residence, and Mailing Address. This basic information is crucial for identification and further communication.
  • Answer the reproductive history questions (#1-3) truthfully. These questions are essential for determining your eligibility for the Family Planning Waiver program.
  • Detail the income sources for all individuals living in your household as requested in question #5. This includes current employment, child care costs for the job, and any other forms of income, providing an accurate picture of your household's financial situation.
  • Attach certified proof of U.S. citizenship and identity, as this is a requirement for processing the application. Acceptable documents include a U.S. Passport or a U.S. Birth Certificate among others.
  • Read the Certification and Authorization section carefully, understanding your rights and the confidentiality of your information, before signing and dating the form.

Conversely, there are actions you should avoid:

  • Do not leave any fields blank, especially those regarding your personal information, household members, and income sources. Incomplete information can delay the processing of your application.
  • Avoid providing unofficial or photocopies of required documents for proof of citizenship and identity. Only originals or certified copies are deemed acceptable.
  • Do not forget to list all household members in question #4, including their relationship to you, Social Security numbers (for yourself), and citizenship status if applicable.
  • Resist the urge to estimate income or provide inaccurate information about your household's financial situation. Precise information is crucial for determining your eligibility and benefits.
  • Do not send the application to Medicaid directly. As instructed, the completed form should be mailed or brought to your local county health department.

Misconceptions

The Florida DH 3212 form, critical for applying for the Health Insurance Application for Extended Family Planning Benefits under a Special Medicaid Program, is often misunderstood. Let’s clarify five common misconceptions.

  • Misconception 1: The DH 3212 form is for general Medicaid applications. The Florida DH 3212 form is specifically designed for the Medicaid Family Planning Waiver program. It is not a general application for all Medicaid services but focuses on family planning services for individuals who have lost full Medicaid benefits and meet other specific criteria.
  • Misconception 2: Any Florida resident can fill out the form. Eligibility for the benefits offered through the DH 3212 form is limited. To qualify, applicants must not be pregnant, have not undergone a hysterectomy or tubal ligation, desire family planning services, and have an income less than or equal to 185% of the current federal poverty level. Not all Florida residents will meet these requirements.
  • Misconception 3: You need to include financial information for all household members. While the form requires detailing household composition and income sources, it specifically requires financial documentation, like income verification, only for the applicant. This is a crucial detail that ensures the privacy and simplifies the process for individuals living in multi-person households.
  • Misconception 4: Proof of U.S. citizenship or identity is optional. The application process mandates the provision of certified proof of U.S. citizenship and identity if the applicant claims to be a U.S. citizen. This requirement underscores the importance of submitting original or certified copies of documents like a U.S. Birth Certificate or Passport, without which the application process cannot be completed.
  • Misconception 5: Submission of this form guarantees immediate enrollment into the program. Completing and submitting the DH 3212 does not assure instant approval or immediate access to benefits. The certification and authorization process involves verification of provided information and a determination of eligibility, which can take time. Additionally, applicants must be aware that failure to completely fill out the application can delay the determination of benefits.

Understanding these nuances about the Florida DH 3212 form can significantly smooth the application process for those seeking family planning services under the Medicaid Family Planning Waiver program.

Key takeaways

Filling out the Florida DH 3212 form is a necessary step for those seeking to apply for the Medicaid Family Planning Waiver program. This process comes with several key takeaways to ensure applicants provide the necessary information accurately and effectively.

  • Eligibility Requirements: To be eligible, applicants should not currently be pregnant, must desire family planning services, should have an income at or below 185% of the federal poverty level, and must not have undergone a hysterectomy or tubal ligation.
  • Importance of Accurate Information: Completing the application with accurate and current information is vital for eligibility determination. Incorrect or incomplete information can lead to delays or denials in receiving benefits.
  • Documentation of Citizenship and Identity: Applicants are required to attach proof of U.S. citizenship and identity. Only original or certified copies of documents like a U.S. Passport or a birth certificate are accepted.
  • Income Reporting: The form requires detailed income information not only from the applicant but also from others living in the household. This includes sources of income, gross income amounts, and how frequently income is received.
  • Disclosure of Living Situation: Applicants must list all persons living in their household, providing details such as the relationship to the applicant, Social Security numbers for applicants, and whether household members are U.S. citizens or not.
  • Health Insurance Information: It is important to disclose any existing health insurance coverage and specify if it includes family planning as a benefit. This information helps to determine the necessity and extent of services provided under the Medicaid Family Planning Waiver program.
  • Consent for Information Sharing: By signing the application, applicants give consent for the Department of Health to access and release their confidential medical and financial information to verify eligibility and coordinate care.
  • Application Submission: The completed application should not be sent to Medicaid but rather submitted to the local county health department. The form's instructions include a reminder to ensure the proper channel is used for application submission to avoid processing delays.

In summary, filling out the Florida DH 3212 form meticulously and providing thorough, accurate information are fundamental steps towards accessing extended family planning benefits through Medicaid. Understanding these key aspects can significantly ease the application process, leading to a timely and favorable eligibility determination.

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