Family and Children's Medicaid MA-3345 AGE/NAME/MARITAL STATUS

II. VERIFICATION PROCEDURES

A. Age

1. Accept applicant's statement unless questionable

2. If questionable, obtain verification from one of the following sources:

a. Birth certificate issued by a governmental body,

b. Hospital records established at the time of birth, including a hospital-issued birth certificate,

c. Social Security Administration records,

(II.A.2.)

d. A notarized statement from the private adoption agency that has custody of a child during the period of adoptive placement.

3. If verification cannot be provided by obtaining one of the sources listed in 2 above, two of the following documents may be used.

a. Driver's license,

b. Marriage license,

c. Bible records,

d. Baptismal or confirmation records,

e. Passport,

f. Military records,

g. School records,

h. Institutional records or physicians' records,

i. Court records, including adoption records,

j. Immigration records,

k. Naturalization records,

l. United States census records, or

m. Witnessed statement of an individual having specific knowledge of the client's age, including:

(1) Name, date, and place of birth of the a/r,

(2) Individual's relationship to a/r, and

(3) Basis of the individual's knowledge

NOTE: Accept witnessed statements of two individuals, in lieu of combination of two documents in 2. if age cannot be verified otherwise.

4. Verification Sources

The following sources are available for verification of births for individuals born in N.C.:

REVISED 11/01/11 – CHANGE NO. 15-11

(II.A.4.)

a. NC Vital Records
1903 Mail Service Center
Raleigh, North Carolina 27699-1903

or

b. The County Health Department where the individual was born. For individuals born in other states, contact the state to determine what agency to contact for birth verification.

c. Children born to U.S. citizens in overseas governmental services:
Authentication Officer
U.S. Department of State
Washington, D.C. 20524

5. If the DMA-5174, Age Verification, form is used the following information must be entered on or attached to the form.

a. The name of the child,

b. The supposed date of birth,

c. The place of birth, i.e., the county, or city and state,

d. The father's name, and

e. The mother's name.

B. Marriage

The client's statement of marriage is acceptable unless questionable. If marriage verification is needed;

1. Request verification from one of the following sources:

a. Copy of marriage license, or

b. Verified information from a county Register of Deeds office or state Vital Records office Use the DMA-5175, Marriage Verification, to request this information.

2. If verification cannot be provided by obtaining one of the sources listed in 1., two of the following documents may be used.

a. Copy of marriage certificate signed by person officiating the wedding and witnesses,

b. Newspaper account,

REVISED 11/01/11 – CHANGE NO. 15-11

(II.B.2.)

c. Bible records,

d. U.S. census records,

e. Immigration/naturalization records, or

f. Witnessed statement from an individual having specific knowledge about the marital status of the applicant/recipient. The statement must include the spouses' names, including the woman's maiden name, their ages, place of marriage, the individual's relationship to the applicant/recipient and the basis of the individual's knowledge. In unusual circumstances when marital status cannot be verified otherwise, the witnessed statement of 2 individuals may be accepted in lieu of the sources listed above.

3. If the DMA-5175, Marriage Verification, is used, the following information must be entered on or attached to the form.

a. The names of the man and woman, including the woman's maiden name,

b. The place of marriage, i.e., the county, or city and state,

c. The ages of the man and woman when the license was issued. If age disagrees with information given at intake, explain why,

d. The addresses of the man and woman at the time marriage license was issued, and

e. The parents' names.

C. Divorce

1. Accept the client's statement of divorce unless questionable.

2. If statement is questionable, verify divorce through legal information such as court documents or through the attorney who handled the divorce.

a. Enter the date of the judgment, the name and location of the issuing court.

b. Show how the information was verified.

(II.C.2.b.)

(1) If by court document, indicate if the document was actually viewed by the IMC.

(2) If the information was provided by a court official, show name and position, how the person was contacted and the date of verification.

(3) If the information was provided by an attorney, indicate what information was provided and the date of verification.

D. Marital Separation

Accept the client's statement of separation unless questionable. If statement is questionable verify by:

1. Legal - Verification of legal separation is the same as in C. above for divorce.

2. Informal - A signed statement from either one of the couple, or two collaterals is acceptable verification of informal separation.

E. Name

1. Accept the client’s statement of his name unless questionable.

2. The name used must match Social Security records. Therefore, enter in EIS the name that appears on the SDX, BENDEX, SOLQ, TPQ, Social Security card, or Medicare card as the person’s name for Medicaid purposes. If a discrepancy exists, use the name from the online verification.