Required Information to Complete an Application
The Department of Human Services Med-QUEST Division (MQD) can process your application faster if you file a complete application. MQD needs to know the following information for each person on the application who is seeking help with insurance:
- Legal name – please do not use nicknames or initials
- Date of birth
- Resident address – if homeless indicate general vicinity and zip code
- Mailing address – if there is no resident address, we need an address where you can get mail
- Social security number – only for people applying for assistance
- Citizenship and alien status – only for people applying for assistance
- Tax filing status – whether you intend to file a tax return and if yes, whether the tax return will be joint and the number of dependents
- Pregnancy and expected date of delivery
- Income – tell us of all the income from wages or other sources such as investments, bank accounts, self-employment, etc.
- Any insurance or other coverage
Those applying for assistance must be U.S. citizens; or lawful permanent residents; refugees; asylees; person granted cancellation of removal, or paroled in the U.S.; nationals of American Samoa or Swain’s Island; Cuban, Haitian, or conditional entrants; Amerasian immigrants; honorably discharged or active duty military, or their spouse or dependent children; battered spouse or children, or children of a battered spouse under the Violence Against Women Act; citizens of Federated States of Micronesia, Marshall Islands, or Palau, or permanently residing in Hawaii under color of law; or otherwise authorized by law to receive assistance.
A social security number is required for each person applying for medical assistance. We will use your social security number to check information against federal and state databases.
Anyone applying for assistance needs to supply citizenship or alien status and a social security number, but it will not hold up a determination if all other information is available. If you are a legal alien, it will be important to know the date of entry. If you do not know it, you can provide it later.
Anyone not applying for assistance does not have to provide citizenship or alien status or a social security number.
Be sure to sign the application. An unsigned application will be returned.
View the Frequently Asked Questions for additional information.