JFS 01958 - Referral for Medicaid Continuing Eligibility Report

Reason for Termination

Select the reason Medicaid coverage was terminated. This is a required field.

Date FACSIS Medicaid Ends

 Enter the date on which FACSIS Medicaid coverage stops. This is a required field.

Is Child Disabled?

Select Yes or No. This is a required field.

Is Caretaker #1 receiving Medicaid health coverage, OWF, or Food Stamps?

Select Yes or No. This is a required field.

Caretaker #1 Primary Language

Select Caretaker #1's primary language.  This is a required field.

Is Caretaker #2 receiving Medicaid health coverage, OWF, or Food Stamps?

Select Yes or No. This is a required field.

Caretaker #2 Primary Language

Select Caretaker #2's primary language.  This is a required field.

Health Insurance Monthly Premium

If the child has other health insurance or a medical support order, enter the monthly premium in this field. If the child does not have other health insurance, enter 0 (zero). This is a required field.

Check Services the Policy Covers

If the child has other health insurance or a medical support order, select all check boxes that apply.