MDHHS-5422, dECLARATION OF rESIDENCY/nO iNCOME OR sUPPORT/iNSURANCE iNELIGIBILITY

Michigan Department of Health and Human Services (MDHHS)

(Revised 6-24)

section 1 – current residence (please print)

Legal Last Name	Middle Initial	Legal First Name

Michigan Drug Assistance Program (MIDAP) Number (if applicable)	Social Security Number

Date of Birth	Phone Number

Street Address	Apartment/Lot/Suite Numbers

City	State	Zip Code

section 2

This declaration form is for client eligibility determination for the following: (check all that apply)

Declaration of Residency

By signing this form, I hereby certify that the residence listed above is the primary residence for the applicant listed below. I understand that this form must be signed by a third party who cannot be a member of my household.

Declaration of No Income or Support

By signing this form, I hereby certify that I have no source of income or additional support. If at any point my circumstances change where I receive an income or support, I will communicate this change to the Ryan White Programs, the Michigan Drug Assistance Program, the Michigan Dental Program, and/or the Housing Opportunities for Persons with HIV (HOPWA) program.

Declaration of Insurance Ineligibility

As an applicant to Ryan White Programs, the Michigan Drug Assistance Program, and/or the Michigan Dental Program, I attest that I am currently ineligible for any other form of health insurance coverage. If at any point my circumstances change, and I become eligible for health insurance coverage, I will take the necessary steps to ensure that I am enrolled in the appropriate health insurance plan. I will communicate my enrollment to Ryan White Programs, the Michigan Drug Assistance Program and/or the Michigan Dental Program.

The Ryan White Programs, the Michigan Drug Assistance Program and the Michigan Dental Program are required to rigorously documented and vigorously pursue that the programs are a “Payer of Last Resort” for all services provided. With the implementation of the Affordable Care Act, Michigan residents have increased access to expanded types of insurance coverage. To ensure compliance with the Federal Payer of Last Resort requirements, clients without insurance are required to submit this completed form for every eligibility determination. The Housing Opportunities for Persons with HIV (HOPWA) program is not a Payer of Last Resort.

section 3 – certification

Applicant’s Printed Name	Applicant’s Signature	Date

section 4 – third party signature for residency only

Third Party Printed Name	Third Party Signature	Date

Third Party Phone Number

section 5

This declaration form is for client eligibility determination for the following: (check all that apply)

Ryan White funded agency programs, ensure a copy is saved in the client file.

Michigan Drug Assistance Program application processing, mail or fax the completed declaration form along with the completed MIDAP application to the address/fax number listed below:

Michigan Drug Assistance Program (MIDAP) Phone: 888-826-6565 Fax: 517-335-7723 PO Box 30727, Lansing MI 48909

Michigan Dental Program application processing, mail or fax the completed MDP application to the address/fax number listed below:

Michigan Dental Program (MDP) Phone: 844-648-3384 Fax: 517-763-0220 PO Box 30815, 5th Floor, Lansing, MI 48909

Housing Opportunities for Persons with HIV (HOPWA) funded agency programs, ensure a copy is saved in the client file.

The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group on the basis of race, national origin, color, sex, disability, religion, age, height, weight, familial status, partisan considerations, or genetic information. Sex-based discrimination includes, but is not limited to, discrimination based on sexual orientation, gender identity, gender expression, sex characteristics, and pregnancy.