D-5400, Notification

Revision 09-4; Effective December 1, 2009

Notify a person applying for Medicaid about the requirement to provide proof of citizenship and identity. A person receiving Medicaid must also be notified at their next annual redetermination, if proof of citizenship and identity is not already in the case record.

Use Appendix XV, Notification to Provide Proof of Citizenship and Identity, to provide information about the requirement and some of the common acceptable sources of documentation of citizenship and identity.

Add a copy of Appendix XV to each application and redetermination packet. If documentation is already in the case record (for example, SOLQ/WTPY showing Medicare entitlement or enrollment), do not add a copy of Appendix XV to the application or redetermination packet.