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Health Insurance and Medical Bills (Medical Assistance Only) You may still get Medical Assistance even if you have other health insurance. We can also pay your Medicare premiums for you. Please tell us about your health insurance. Medicar e Does anyone have Medicare (a red, white and blue card)? If YES, who has Medicare? ______________________________ �� Yes �� No Health Insuranc e Does anyone have any other insurance? If YES, please give us a copy of the insurance card. �� Yes �� No Retro Medicaid/ Medical Bill s Did anyone have any medical bills in the last three months? If you get DC Medicaid, you can get paid back for some bills that you have paid. We can also pay some unpaid bills. Call (202) 698-2009. Were your address, income, and assets the same as now during the last three months? If no, describe the change. �� Yes �� No �� Yes �� No Voluntary Questions Ethnicity : �� Hispanic/Latino �� Not Hispanic/Latino Race : �� Black/African-American �� Asian �� American Indian or Alaskan Native �� White �� Native Hawaiian or Other Pacific Islander Note: You may check more than one race. Also, you do not have to provide this information. None of this information will affect your benefits. We only ask for this information to make sure that we do not discriminate. Language Preference The DC Language Access Act requires that we provide services for persons who do not speak English or cannot speak English well. The law also requires that we collect information on the languages that our customers use. Please answer the following questions: What is the Language that you usually speak? �� English �� Spanish �� French �� Vietnamese �� Korean �� Amharic �� Chinese (Mandarin) �� Chinese (Cantonese) �� Other __________________________ What Language do you want to use to get ESA services? �� English �� Spanish �� French �� Vietnamese �� Korean �� Amharic �� Chinese (Mandarin) �� Chinese (Cantonese) �� Other __________________________ If you do not want to use the language that you usually speak, you must sign the statement below: I have been told that I have the right to receive ESA services in the language that I usually speak. By signing below, I am saying that I do NOT want language services. Sign here only if you do NOT want language services: ____________________________________ December 201 5 7 0f 8


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