DHS-3243 (Rev. 10-14) Bridges
RETROACTIVE MEDICAID APPLICATION
My family has unpaid medical bills for the month(s) of:
ANSWER QUESTIONS 2-9 FOR EACH MONTH APPLIED FOR IN QUESTION 1.
List yourself and the name of each family
member who lived with you at any time during
the first month or who you claim as a
dependent on your tax return. Check yes if the
person has unpaid medical expenses this
List yourself and the name of each family
member who lived with you at any time during
the second month or who you claim as a
dependent on your tax return. Check yes if the
person has unpaid medical expenses this
List yourself and the name of each family
member who lived with you at any time during
the third month or who you claim as a
dependent on your tax return. Check yes if the
person has unpaid medical expenses this
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
Was a family member(s) in a hospital, nursing
home, or away from home on the last day of
the first month?
YES NO
If YES, enter name of family member(s):
Was a family member(s) in a hospital, nursing
home, or away from home on the last day of
the second month?
YES NO
If YES, enter name of family member(s):
Was a family member(s) in a hospital, nursing
home, or away from home on the last day of
the third month?
YES NO
If YES, enter name of family member(s):
Explain any changes during the first month
(child born, family member left or returned
home, married, divorced, died, began or ended
pregnancy, began or quit work) and indicate
Explain any changes during the second month
(child born, family member left or returned
home, married, divorced, died, began or ended
pregnancy, began or quit work) and indicate
Explain any changes during the third month
(child born, family member left or returned
home, married, divorced, died, began or ended
pregnancy, began or quit work) and indicate
over