NOW YOU CAN AFFORD PEACE OF MIND.

Sample - Use Blue or Black Ink
Yes
BOX
No T E S T

Correspondencia en Español
(Check this option if you would like to receive Correspondence in Spanish)

You can also apply online by visiting www.peachcare.org

PeachCare Application

If you have ever applied for PeachCare for KidsTM - or - have ever been on PeachCare for KidsTM please call 877-GA PEACH
(427-3224). Filling out a new application will delay your processing.

Section 1. Parent/Guardian Information (Person to whom correspondence should be directed.) List only people currently living in the household.
PARENT ONE:

M
F

Name
First

M.I.

Last

Suffix

Sex

Date of Birth MM/DD/YY

Street Address:
Number and street, including apartment number
City

State

Zip Code

County

Mailing Address:
(If different from street address)

Number and street, including apartment number

City

State

Zip Code

County

Home Telephone:

(

)

Emergency Telephone:

(

)

Social Security Number:
Business Telephone: (

)

E-Mail Address: ______________________________________
PARENT TWO: Does parent two live in household? Yes

No

Name
First

M.I.

(List parent two only if he/she lives in household.)
M
F
Last

Social Security Number:

Suffix

Business Telephone:

Sex

(

Date of Birth MM/DD/YY

)

Section 2. Child Information. List all children under 19 years old in your home. (If there are more than 3 children in household for whom you wish to
CHILD ONE:

apply, please attach a separate sheet.) The name of the child(ren) should be the same as it appears on the child(ren)’s birth certificate.
M
Name
F
First
M.I.
Last
Sex
Date of Birth MM/DD/YY
U.S. Citizen? Yes

No

Race

Social Security Number
What state was the child born in?
Has Health Insurance? Yes

American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White

What county was the child born in?
No

Name of Insurance Company

Policy #

Medicaid #

Relationship to Parent #1:
Relationship to Parent #2:
CHILD TWO:

Child
Child

Stepchild
Stepchild

Grandchild/relative
Grandchild/relative

Other
Other

Last

M
F
Sex

Name
First
U.S. Citizen? Yes

M.I.
No

Race

Social Security Number
What state was the child born in?
Has Health Insurance? Yes

Date of Birth MM/DD/YY

American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White

Other

What county was the child born in?
No

Name of Insurance Company

Policy #

Medicaid #

Relationship to Parent #1:
Relationship to Parent #2:
CHILD THREE:

Other

Child
Child

Stepchild
Stepchild

Grandchild/relative
Grandchild/relative

Other
Other

Last

M
F
Sex

Name
First
U.S. Citizen? Yes

M.I.
No

Race

Social Security Number
What state was the child born in?
Has Health Insurance? Yes

Other

What county was the child born in?
No

Name of Insurance Company

Policy #
Relationship to Parent #1:
Relationship to Parent #2:

Date of Birth MM/DD/YY

American Indian or Alaska Native
Asian
Black or African American
Hispanic or Latino
Native Hawaiian or Other Pacific Islander
White

Medicaid #
Child
Child

Stepchild
Stepchild

Grandchild/relative
Grandchild/relative

Other
Other

Section 3. Insurance Information
Is either parent employed by the State of Georgia, a public school system or the Board of Regents?

Yes

No

If yes, please specify ________________________________________________________________ Is this employment: Full Time
Have any children you are applying for lost health insurance coverage (not Medicaid) in the past six months?

Yes

Part Time

No

If yes, explain: _______________________________________________________________________ Last date of coverage:
MM/DD/YY

You may name your current doctor if he/she participates in Georgia Better Health Care. If you don’t make a choice, you will be assigned to a doctor convenient to where you live. You may change your selection later by calling 770-570-3373 (metro Atlanta) or 1-866-211-0950 (Toll-Free).

Section 4. Income and Daycare*
List ALL income received BY parents and children listed on your application. Do not list income for parent who DOES NOT live at this address. Do not list income of a legal guardian or other non-parent. Be sure to show the amount of income BEFORE TAXES and other deductions. Attach an extra sheet if needed.
INCOME:

AMOUNT
HOW OFTEN?
BEFORE Taxes and Other Deductions (Weekly, Monthly, Every 2 weeks, Etc.)

NAME OF PERSON RECEIVING
(Include only income of the children/parents at the address listed on the application)

DID YOU INCLUDE
PROOF OF INCOME?

Current employer’s name:
Yes

No

__________________________

Yes

No

Social Security (RSDI)

Yes

No

Supplemental Security Income

Yes

No

Workers’ Compensation

Yes

No

Pensions or Retirement Benefits

Yes

No

Child Support
(List amount each child receives.)

Yes

No

Contributions

Yes

No

Unemployment Benefits

Yes

No

Other Income, please specify:
__________________________

Yes

No

__________________________
Current employer’s name:

* Do you pay for childcare (or care for an adult who cannot care for himself/herself) so that someone in your household can work?
NAME OF PARENT
WHO WORKS

NAME OF CHILD OR
ADULT CARED FOR

UNDER THE AGE OF 2 ?
Yes

HOW OFTEN?
(Weekly, Monthly, Etc.)

No

Yes

AMOUNT
PAID

No

Yes

NAME OF DAY CARE
OR CAREGIVER

No

Section 5. Proof of Income and Citizenship
You must include the most recent copies of proof of all your income. These are the types of information you need to send with your application:
For money you earn by doing a job or service, you must send:
Weekly pay - (4) weeks of pay stubs (one week after the other)—OR—Bi-Weekly pay - (2) pay stubs received every other week (one after another)—
OR—Semi-Monthly - (2) pay stubs received two times a month (one after the other)—OR—Monthly - (2) pay stubs received one time a month (one month after another)—OR—Paid Cash - Letter from Employer signed by an Officer of the Company on Company letterhead—OR—Yearly - Tax Forms filed—OR—Self Employment Documents - such as business ledger receipts—OR—Bank Deposits.
Please show proof of money anyone in the household receives from any agencies, parents or relatives, or any other sources. This might include:
• SSI or SSA - Current year award letter • Unemployment check - (4) weeks of pay stubs (one week after the other) • Workers’ Compensation letter from insurance company stating amount received and how often received, provide contact name and number. • Contributions - letter from person who gives you money, provide name, address and contact number. Provide amount received and how often received. • Child Support (paid directly to you) - written statement from the parent who gives you money, provide the name, address and contact number. Provide amount received and how often received. • Child Support (paid through court) - court papers or letter stating the amount of income received and how often it is received. • Other
Unearned Income - provide letter stating amount received and how often received. Provide name, address and contact number or (4) weeks of pay stubs
(one week after the other). Citizenship or legal immigration status must be verified for eligibility in PeachCare or Medicaid. PeachCare may request proof of citizenship or legal immigration status. Failure to comply will result in a denial of your application. Social Security Numbers are used to do computer matches with other agencies in order to assist in verifying eligibility for PeachCare and/or Medicaid benefits. You only need to tell us the
Social Security Number for the people for whom you are applying.

Section 6. Pregnancy
Is anyone in the household pregnant?

Yes

No

If yes, who? _____________________________________________________

Section 7. Certification, Understanding, and Authorization
I understand that this information will be verified to determine eligibility. I understand that information supplied by the Georgia Department of Labor, Georgia
Department of Revenue, the Social Security Administration or other agencies may be disclosed to a third party administrator to verify and determine eligibility for PeachCare. I agree to cooperate with PeachCare for KidsTM , the Georgia Department of Community Health, and the Georgia Division of Family and Children Services to verify income, resources, citizenship and identification. I agree to assign to the state all rights to medical support and third party support payment (hospital and medical benefits).
I understand that I must report changes in my address, income, resources, and circumstances within ten (10) days of becoming aware of the change. I attest to the identity/citizenship/legal residency status of the children listed and I certify under penalty of perjury that all of the information provided on this application is true and correct to the best of my knowledge.
PLEASE NOTE: If your child is not eligible for PeachCare, he/she might qualify for Medicaid. Your application will be referred to Medicaid for review.
Medicaid offers the same benefits as PeachCare and does not require a premium. Medicaid may be able to assist with unpaid medical bills from the past three months. If your child(ren) is eligible for Medicaid, you must agree to apply for a Social Security number for your child(ren).
Do you have any unpaid medical bills from the past three months? Yes

No

If yes, what month(s)_________________________

I authorize release of personal and financial information to PeachCare for KidsTM, the Georgia Department of Community Health and the Division of
Family and Children Services. I understand that my case may be subject to a quality control review and I agree to cooperate in the review process.
SIGNATURE OF PARENT OR GUARDIAN: (REQUIRED) _____________________________________________________ Date ______________
Where did you get this application? Dr.’s Office/Hospital
1-877-GA-PEACH
Once your application has been approved, you will receive a letter letting you know the amount of your monthly premium.

School/Daycare

Health Dept.

Caseworker

Other
Check/Money Order attached?

Yes

No

Please mail application and income documents to:
PeachCare for KidsTM
P Box 2583
.O.
Atlanta, GA 30301-2583
Faxed applications are not accepted.

Georgia Department of Community Health
Rev 10/01/10

Amount ____________________

Si desea una aplicación en español, por favor llame gratis al 1-877-427-3224.

Eligibility will not be affected by race, color, national origin, age, disability, or sex except where it is required by law.