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Six Month Self-Attestation of Eligibility Changes: Staff Name: Agency/Program: Phone #: Fax #

This document outlines the requirements for a six month self-attestation of eligibility for a program. It requests recipients to update their income, insurance status, and residency information by a certain due date. Documentation may be required to verify any changes, such as tax forms, pay stubs, insurance cards, or documents showing an address change. The recipient must sign to attest the information provided is accurate to the best of their knowledge.

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42 views

Six Month Self-Attestation of Eligibility Changes: Staff Name: Agency/Program: Phone #: Fax #

This document outlines the requirements for a six month self-attestation of eligibility for a program. It requests recipients to update their income, insurance status, and residency information by a certain due date. Documentation may be required to verify any changes, such as tax forms, pay stubs, insurance cards, or documents showing an address change. The recipient must sign to attest the information provided is accurate to the best of their knowledge.

Uploaded by

ben
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Six Month Self-Attestation of Eligibility Changes

THMP eligibility requires an update to your eligibility every six (6) months. Please answer all questions below and
provide any required documents for changes in your income, insurance status or residency. THMP will require this
information by the date listed on the enclosed letter (Your Self Attestation will be due 6 months after your birth
month).

Phone
Name: Number:

Social Security Number: Date of Birth:


Residential address:

Address►
(please provide your
current address)
Mailing address:

If you have moved, please include a copy of your driver’s license with your new residential address, utility
bill, rental agreement, or other documentation of your new address

Income (Includes income of legal or common law spouse if married)

I/We have no income If your income has changed since your last recertification,
please include appropriate documentation of a tax return
My/Our income has not changed
form, two consecutive paystubs, Social Security award
My/Our income has changed letter, or other documentation to prove your income.

Insurance Status

Medicaid ACA health plan If you have insurance coverage of any kind,
please include front and back copies of your
Medicare Private Insurance
insurance cards. You will also need to
Medicare Part D No Form of Insurance complete and submit the Co Pay
Assistance enrollment form (pg. 6 of the
application)
Client or
Staff
Signature: Date:
I attest that my signature on this form indicates the information provided is accurate and complete to the
best of my knowledge.

***In person attestations must be signed by the client. Phone attestations must include the name,
signature, and agency name of the staff member completing the form. ***

Staff Name: Agency/Program: Phone #: Fax #:

___________________________ ____________________________ _______________ _______________

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