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  • PART I ADMINISTRATION OF THE GOVERNMENT
  • TITLE XVII PUBLIC WELFARE
  • CHAPTER 118E DIVISION OF MEDICAL ASSISTANCE
  • Section 20 Application; forms; application by institution

Section 20. An application or reapplication by an individual for medical assistance shall be made to the division on forms prepared by the division. Such forms shall include but not be limited to the following:—the name, address and social security number of the applicant and the name, address and social security number of any member of the family sixteen years of age and older, the total income from wages, salaries, pensions, fees, tips, bonuses and all other sources of income of all such persons, the ownership and description of any motor vehicle or boat, or trailer, or similar assets readily convertible into cash owned by any member of the family. Such form shall require that the applicant provide information to determine his or her eligibility for medical assistance under penalty of perjury.

An institution furnishing services under this chapter shall have the right to make such application on behalf of an individual only if, and to the extent, provided by regulations of the division.