Katie Beckett Application Packet

To apply for Medical Assistance through the Katie Beckett provision, a parent or guardian would need to complete the following forms in the application packet:

• Katie Beckett Application
• Parent/Guardian Questionnaire
• Bank Account Verification Forms
• Third Party Liability (TPL) Reporting Form
• Verification of Citizenship/Alienage Form
• Racial/Ethnic Heritage Form
• Physician Evaluation Form
• Authorization for Disclosure/Use of Health Information
• Rights and Responsibilities Notice
• HIPAA Privacy Notice
• Supplement for Citizenship and Identity Verification

In addition, parents/guardians are encouraged to send in copies of recent evaluations by medical or behavioral specialists, the Early Intervention Program (IFSP), Special Education (IEP), or other providers who have evaluated the child.  Parents may also be asked for additional clinical information or DHS may request it directly from a provider (with the parent's signed authorized release).