Homepage Fill Out a Valid Nevada Check Up Template
Outline

The Nevada Check Up (NCU) form serves as an application gateway for the Children's Health Insurance Program (CHIP) within Nevada, presenting a structured pathway for securing low-cost health care coverage for uninsured children up to 18 years old. This form encompasses a comprehensive set of sections aimed at collecting detailed information about the child(ren) for whom the coverage is sought, including their names, citizenship status, health insurance details, and any disabilities or special conditions. It requires the applicant to indicate whether the application should be referred to Nevada Medicaid if it appears the children may be eligible, thereby integrating a check for Medicaid eligibility directly into the application process. Detailed employment and income information for all household adults, alongside other income sources, are solicited to assess eligibility based on federal income guidelines. Furthermore, it touches on health plan selection, emphasizing the program's focus on providing medically necessary services, including medical, dental, and vision care for children. The form also carries important notes on the application's implications for immigration status, the responsibility of the applicant to report any changes that might affect eligibility, and the consequences of providing false information, punctuated with details on premium payments scaled by family income and size. Through this meticulously designed application process, the Nevada Check Up program encapsulates its commitment to the health and welfare of children within the state, ensuring that necessary healthcare services are accessible to those in need based on defined eligibility criteria.

Sample - Nevada Check Up Form

Other Adults in Household:

Nevada Check Up (NCU) Application

Children’s Health Insurance Program (CHIP)

Questions regarding this

application? Call:

1-877-KIDS NOW (543-7669)

If previously on Nevada Check Up, please enter family identification number:

Note - We will review your application for possible Medicaid eligibility. If it appears your children may be eligible for Medicaid, we will deny NCU enrollment and may refer your case to the Division of Welfare and Supportive Services (DWSS) for a Medicaid eligibility review.

1)Do you want this application to be referred to Nevada Medicaid if applicable? Yes No

2)Are you currently applying for Medicaid medical assistance for any of the individuals listed? Yes

No

Person or Head of the Household Applying for Child(ren): Please fill in all the information about the person

applying for the child(ren).

 

(1) Last Name

 

 

 

 

 

 

 

 

 

 

 

 

 

Male Female

 

 

First Name

MI

 

 

Social Security Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth

 

 

Marital Status

 

 

 

Race/Ethnicity (OPTIONAL)

 

 

 

 

 

 

Married

Single

 

 

African American

Asian

Caucasian/White

Other

 

 

 

 

 

 

 

Hispanic

American Indian or Alaska Native

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Citizenship Status - Information received on citizenship status is not reported to INS

 

 

Preferred Language

 

U.S. Citizen

Undocumented Alien

Lawful Permanent Resident (LPR) as of (Date):

 

 

English

Spanish

 

 

 

 

 

 

 

 

 

 

 

Home Address - Number, Apt/Space and Street

 

 

 

City and State

 

 

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

Mailing address (if different than home)

 

 

 

City and State

 

 

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home Number

 

 

Cell/Message

 

 

 

Work Number

 

 

How many people in

 

 

 

 

 

 

 

 

this household?

 

 

 

 

 

 

 

 

 

 

 

 

 

(

)

 

(

)

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

*Will this household continue to live in Nevada? Yes *Is your rent or mortgage subsidized by an agency? No

No, explain Yes, amount

List all adults in the household regardless of relationship to child(ren) for which you are applying. If more adults reside in the household, please attach an additional sheet with the same information in the same order as listed below:

 

(1) Last Name

Male

Female

 

 

First Name

MI

 

 

Social Security Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth

 

Marital Status

 

 

 

Race/Ethnicity (OPTIONAL)

 

 

 

 

Married

Single

 

 

African American

Asian

Caucasian/White

Other

 

 

 

 

Hispanic

American Indian or Alaska Native

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Citizenship Status- Information on citizenship is not reported to INS

U.S. Citizen Undocumented Alien Lawful Permanent Resident (LPR) as of (Date):

Relationship to applicant above Spouse Sibling Child Parent Other Relative Other :

 

(2) Last Name

Male

Female

 

 

First Name

MI

 

 

Social Security Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Birth

 

Marital Status

 

 

 

Race/Ethnicity (OPTIONAL)

 

 

 

 

 

Married

Single

 

 

African American

Asian

Caucasian/White

Other

 

 

 

 

 

Hispanic

American Indian or Alaska Native

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Citizenship Status- Information on citizenship is not reported to INS

U.S. Citizen

Undocumented Alien

Lawful Permanent Resident (LPR) as of

 

 

(Date):

Relationship to applicant above

Spouse Sibling Child Parent Other Relative Other :

Page 1 of 6

NCU-0100 (06/10)

Children in Household:

List all children even if they are not U.S. citizens. If more than four children reside in the household, please attach an additional sheet with the same information in the same order as listed below. If Birth Certificates are available, please provide a copy.

(1) Last Name

Male

Female

 

 

First Name

 

MI

Social Security # (REQUIRED)

Date of Birth

 

Marital Status

 

 

 

 

Race/Ethnicity (OPTIONAL)

 

 

(REQUIRED)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Single

 

Married

 

 

African American

Asian

Caucasian/White

Hispanic

 

 

 

 

 

 

American Indian/Alaska Native

 

Other:

 

 

 

 

 

 

 

 

 

 

 

Citizenship Status (REQUIRED)

 

 

Is this child

 

Are you applying for

Is this child disabled

*Information on citizenship is not reported to INS

 

pregnant?

 

NCU for this child?

and receiving SSI?

U.S. Citizen

Undocumented Alien

 

 

Yes

No

 

Yes

No

 

 

Yes

No

Lawful Permanent Resident - provide copy of card

Due date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Health Insurance

 

 

 

 

 

Parental Relationship (REQUIRED)

 

On Nevada Medicaid

Yes, name of insurance:

 

Name of mother :

 

 

 

 

 

No Coverage

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date coverage ended:

Type of insurance:

 

 

 

Name of father:

 

 

 

 

 

 

 

Cancer

Dental/Vision

 

Pharmacy

 

 

 

 

 

 

 

 

Reason:

 

Managed Care (HMO/PPO)

 

Relationship of child to applicant :

Child

Other:

 

 

Major Medical

Medicare A, B, or D

 

Step-Child

None

Niece/Nephew

 

Child Care Expenses - complete if applicable

Amount Paid:

 

 

 

How often paid:

 

 

(2) Last Name

Male

 

Female

 

 

First Name

 

MI

Social Security # (REQUIRED)

Date of Birth

 

Marital Status

 

 

Race/Ethnicity (OPTIONAL)

 

 

(REQUIRED)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Single

Married

African American

 

Asian

Caucasian/White

Hispanic

 

 

 

 

American Indian/Alaska Native

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Citizenship Status (REQUIRED)

Is this child

 

Are you applying for

 

Is this child

 

 

disabled and

*Information on citizenship is not reported to INS

pregnant?

 

NCU for this child?

 

 

 

receiving SSI?

 

 

 

 

 

 

 

 

 

 

 

U.S. Citizen

Undocumented Alien

Yes

No

 

 

 

 

 

 

 

 

 

Yes

No

 

Yes

No

Lawful Permanent Resident - provide copy of card

Due date:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Health Insurance

 

 

On Nevada Medicaid

Yes, Name of Insurance:

 

No Coverage

 

 

 

Date coverage ended:

Type of insurance:

 

 

 

 

Cancer Dental/Vision

Pharmacy

Reason:

Managed Care (HMO/PPO)

 

 

 

Major Medical

Medicare A, B, or D

Parental Relationship (REQUIRED)

Name of mother :

Name of father:

 

 

 

 

 

 

 

 

Relationship of child to applicant:

Child

Other:

Step-Child

None

Niece/Nephew

 

Child Care Expenses - complete if applicable

Amount Paid:

 

 

How often paid:

 

 

(3) Last Name

Male

Female

 

 

First Name

MI

Social Security # (REQUIRED)

Date of Birth

 

Marital Status

 

 

 

 

Race/Ethnicity (OPTIONAL)

 

 

(REQUIRED)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Single

Married

 

 

African American

Asian

Caucasian/White

Hispanic

 

 

 

 

 

American Indian/Alaska Native

Other:

 

 

 

 

 

 

 

 

 

Citizenship Status (REQUIRED)

 

 

Is this child

Are you applying for

Is this child disabled

*Information on citizenship is not reported to INS

 

pregnant?

NCU for this child?

and receiving SSI?

U.S. Citizen

Undocumented Alien

 

 

Yes

No

Yes

No

 

 

Yes

No

Lawful Permanent Resident - provide copy of card

Due date:

 

 

 

 

 

 

 

 

 

 

 

 

Health Insurance

 

 

 

 

Parental Relationship (REQUIRED)

 

On Nevada Medicaid

Yes, Name of Insurance:

 

Name of mother :

 

 

 

 

 

No Coverage

 

 

 

 

 

 

 

 

 

 

 

 

 

Date coverage ended:

Type of insurance:

 

 

 

Name of father:

 

 

 

 

 

 

 

Cancer

Dental/Vision

 

Pharmacy

 

 

 

 

 

 

 

Reason:

 

Managed Care (HMO/PPO)

 

Relationship of child to applicant:

Child

Other:

 

 

Major Medical

Medicare A, B, or D

Step-Child

None

Niece/Nephew

 

Child Care Expenses - complete if applicable

Amount Paid:

 

 

How often paid:

 

 

Page 2 of 6

 

 

 

 

 

 

 

 

 

 

 

NCU-0100 (06/10)

(4) Last Name

Male

Female

 

 

First Name

MI

Social Security # (REQUIRED)

Date of Birth

 

Marital Status

 

 

 

 

Race/Ethnicity (OPTIONAL)

 

 

(REQUIRED)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Single

Married

 

 

African American

Asian

Caucasian/White

Hispanic

 

 

 

 

 

American Indian/Alaska Native

Other:

 

 

 

 

 

 

 

 

 

Citizenship Status (REQUIRED)

 

 

Is this child

Are you applying for

Is this child disabled

*Information on citizenship is not reported to INS

 

pregnant?

NCU for this child?

and receiving SSI?

U.S. Citizen

Undocumented Alien

 

 

Yes

No

Yes

No

 

 

Yes

No

Lawful Permanent Resident - provide copy of card

Due date:

 

 

 

 

 

 

 

 

 

 

 

 

Health Insurance

 

 

 

 

Parental Relationship (REQUIRED)

 

On Nevada Medicaid

Yes, Name of Insurance:

 

Name of mother :

 

 

 

 

 

No Coverage

 

 

 

 

 

 

 

 

 

 

 

 

 

Date coverage ended:

Type of insurance:

 

 

 

Name of father:

 

 

 

 

 

 

 

Cancer

Dental/Vision

 

Pharmacy

 

 

 

 

 

 

 

Reason:

 

Managed Care (HMO/PPO)

 

Relationship of child to applicant:

 

Child

Other:

 

 

Major Medical

Medicare A, B, or D

Step-Child

None

Niece/Nephew

 

Child Care Expenses - complete if applicable

Amount Paid:

 

 

How often paid:

 

Employment Information: List employment information for each adult residing in the household. *See insert for acceptable income verification (not more than 45 days old).

 

(1) Person Employed - Last, First

 

 

 

Name of Employer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer Address

 

Employer Telephone

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

Gross Pay - amount before taxes

 

Tips per pay period

 

 

How Often Paid

 

 

 

 

 

 

 

 

 

Weekly

Every 2 weeks

Twice a month

Monthly

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(2) Person Employed - Last, First

 

 

 

Name of Employer

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Employer Address

 

Employer Telephone

 

 

 

 

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

Gross Pay - amount before taxes

 

Tips per pay period

 

 

How Often Paid

 

 

 

 

 

 

 

 

 

Weekly

Every 2 weeks

Twice a month

Monthly

Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other Income: Please provide the most current proof (not more than 45 days old) for each income received. List all types of income received by anyone in the household (including children) and leave blank if not applicable.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Source of Other Income

 

 

Name of Recipient

 

 

Dollar

 

 

 

How Often Paid

 

 

 

 

 

 

 

 

 

 

 

 

 

Amount

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Child Support/Alimony

 

 

 

 

 

 

 

Weekly

Every 2 weeks

Other:

 

 

 

 

 

 

 

 

Twice a month

Monthly

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Social Security Payments - select

 

 

 

 

 

 

 

Weekly

Every 2 weeks

Other:

 

RSDI

SSI

 

 

 

 

 

 

 

Twice a month

Monthly

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Disability Payment Source

 

 

 

 

 

 

 

Weekly

Every 2 weeks

Other:

 

 

 

 

 

 

 

 

Twice a month

Monthly

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Unemployment Benefits

 

 

 

 

 

 

 

Weekly

Every 2 weeks

Other:

 

 

 

 

 

 

 

 

Twice a month

Monthly

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Pension Payment and Source

 

 

 

 

 

 

 

Weekly

Every 2 weeks

Other:

 

 

 

 

 

 

 

 

Twice a month

Monthly

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Interest or Dividends (Stocks, Bonds,

 

 

 

 

 

 

 

Weekly

Every 2 weeks

Other:

 

 

 

 

 

 

 

 

Twice a month

Monthly

 

 

Trusts, Mutual Funds, Savings, etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other (such as cash assistance, etc)

 

 

 

 

 

 

 

Weekly

Every 2 weeks

Other:

 

 

 

 

 

 

 

 

Twice a month

Monthly

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 3 of 6

 

 

 

 

 

 

 

 

 

 

 

NCU-0100 (06/10)

Health Plan Selection: Please choose a health plan:

*Note: If you do not choose a health plan preference, we will choose a plan for you (see insert for choices).

Referral Information: How did you hear about Nevada Check Up? (Please check the ONE that applies)

Covering Kids and Families

Welfare

School

WIC

Media (Newspaper, TV and Radio)

Internet

Friend/Family

Doctor/Hospital

Social Services/Health Dept

Child Care Provider

Tribal Resource

Clinic

Other:

 

 

Signature and Affirmation:

It is your responsibility to immediately report to Nevada Check Up any of the following status changes for your children:

OChange of address and phone number

OMoves out of the house or state

OChild(ren) becomes eligible for Medicaid or other health insurance

OA household member becomes deceased

OChild(ren) becomes a resident, inmate of a public institution or a ward of the state

OChild(ren) becomes emancipated and/or married

In signing this document, I hereby apply for health insurance coverage for the named children under the Nevada Check Up program. I agree to adhere to all the required responsibilities to report changes listed on this application. I certify that all information contained is true and accurate to the best of my knowledge and that no facts have been left out.

I hereby release Nevada Check Up from liability, if any, resulting from the disclosure of information contained in this application.

I understand and authorize Nevada Check Up and/or the Department of Health and Human Services to contact any party deemed necessary to verify information presented on the application.

If any of my household members receive Nevada Check Up, I agree to assign all rights to any medical claims, medical support or other payments for medical care. I understand this is a condition of being eligible for Nevada Check Up. I agree to cooperate with the division in obtaining payments for medical care from any third party or person who may be liable for the medical services paid for by Nevada Check Up. I also understand I must inform Nevada Check Up if any legal action is taken against anyone or if I receive any offer or settlement for the reimbursement of medical care and treatment that may be paid for by Nevada Check Up.

I understand the eligibility determination process may take 45 days. The 45 days starts when a complete application with all necessary, requested and required documentation is received. Once approved, I will be notified by mail of the date coverage begins and my premium amount. If the application is denied or Nevada Check Up makes any other decision with which I don’t agree, including timeliness of the determination within established guidelines, I have the right to request a hearing. The request for hearing must be submitted in writing within 30 days of the date of the denial letter.

A reproduced copy of this authorization constitutes an original copy.

I declare under penalty of perjury under the laws of the State of Nevada that the foregoing is true and correct. (NRS 53.045, NRS 199.120 thru NRS 199.200 and NRS 41.365).

I further understand that the law provides penalties for persons hiding facts or not being completely truthful.

I understand that information provided to NCU may be verified or investigated by federal, state and local officials. If I do not cooperate in the investigation, my child(ren)’s benefits will be denied or terminated. If I make false or misleading statements;

misrepresent, conceal or withhold facts; or alter any document necessary to make an accurate eligibility determination, my child(ren)’s benefits may be denied or terminated. I am responsible for repayment of all monies paid for services to which my

child(ren) were not entitled and I may be subject to any criminal and/or civil penalties in accordance with state and federal law.

Applicant Signature:

 

Date:

 

 

 

 

(Mandatory) If not signed, application will be rejected.

Other Adult:

 

Date:

 

 

 

 

Send your completed application or any correspondence to: Nevada Check Up Program 1000 E. William Street Ste 200 Carson City, Nevada 89701

Questions? Call us at (775) 684-3777 or toll free 1-877-KIDS-NOW (543-7669). Our fax number is (775) 684-8792. Spanish speaking staff is always available! You may also visit us on our website: http://nevadacheckup.nv.gov

If you believe someone has interfered with your right to register to vote, your right to choose your own political party or other political preference, you may file a complaint with the Office of the Secretary of State, Capitol Complex, Carson City, Nevada 89710.

The Department of Health and Human Services, Division of Health Care Financing and Policy, provides services without discrimination of any kind due to race, national origin, color, gender, religion, age or disability (including AIDS and related conditions) as required by federal law.

Page 4 of 6

NCU-0100 (06/10)

1-877-KIDS-NOW (543-7669)

Nevada Check Up

Fax (775) 684-8792

1000 E Williams Street, Suite 200

 

Carson City, NV 89701

What is Nevada Check Up?

The state of Nevada Children’s Health Insurance Program (CHIP) known as “Nevada Check Up” is a federal and state funded program that provides low-cost health care coverage to uninsured children from birth through 18 years of age who meet the program guidelines.

What health services are covered?

Most medically necessary services are covered. Nevada Check Up offers comprehensive medical, dental and medical vision care for children.

What are the eligibility qualifications for Nevada Check Up?

2011

Number of

200% FPL

People in

Max Income

Household

Level

2

$29,420

 

 

3

$37,060

 

 

4

$44,700

 

 

5

$52,340

 

 

6

$59,980

 

 

Children must meet the following conditions:

Not be covered by or appear eligible for Medicaid

Have no other health care coverage or had insurance in the last six months

Not be covered by or have access to the Public Employee Benefits Program (PEBP)

Be a citizen of the United States or a Lawful Permanent Resident (LPR) for five years O Please note that applying for Nevada Check Up will not affect your family’s

immigration status

Meet federal income guidelines (be within 200% of the Federal Poverty Level)

OApplicants that currently exceed the listed 200% FPL may still qualify for our program in the future as the Federal Poverty Levels can change

Be younger than 18 years and 11 months at the time of the application

What about premium payments?

The only cost for Nevada Check Up is a quarterly premium which is determined by family size and income. The premium is charged per family, not per child. Below is a chart which shows the premium amount associated with the Federal Poverty Level (FPL). For American Indian families who are members of federally recognized tribes, or an Eskimo, Aleut or other Alaska Native enrolled by the Secretary of the Interior, quarterly premiums are waived when proof of status (copy of the tribal affiliation card) is provided.

Premium

FPL

 

 

$25

From 36% up to 150%

 

 

$50

From 151% up to 175%

 

 

$80

At or above 176%

 

 

Families are informed of their premium amount once they are enrolled. If families are enrolled during a quarter premiums will be prorated. If your child(ren) were previously on NCU and have an existing unpaid premium balance, children will not be enrolled until payment is received. Payment arrangements can be made which would not exceed 60 days.

Note - Failure to pay premiums will result in disenrollment

Quarters

Due Date

 

 

1st Quarter

October 1st

Oct, Nov, Dec

 

 

 

 

 

 

 

 

 

2nd Quarter

January 1

st

Jan, Feb, Mar

 

 

 

 

 

 

 

 

 

 

3rd Quarter

April 1

st

 

Apr, May, Jun

 

 

 

 

 

 

 

 

 

 

4th Quarter

July 1

st

 

Jul, Aug, Sept

 

 

 

 

 

 

 

 

 

 

 

 

Page 5 of 6

PLEASE KEEP FOR YOUR RECORDS

NCU App Insert English (06/10)

1-877-KIDS-NOW (543-7669)

Nevada Check Up

Fax (775) 684-8792

1000 E Williams Street, Suite 200

 

Carson City, NV 89701

How often must I re-qualify for Nevada Check Up?

Once a year, Nevada Check Up will send a request for updated information. Recipients will also be requested to send new income verification documents. If you do not respond by the deadline, your children will no longer be covered by Nevada Check Up. Families will only receive notification if their case will be disenrolled.

Health Plan

Families who live in urban Washoe County or urban Clark County are covered by a Managed Care Organization (MCO). You are asked to choose one of the following health plans on page four of the application under Health Plan Selection. If you do not indicate a health plan preference on your application, we will choose a plan for you. Your choice of health plan does not guarantee acceptance into the Nevada Check Up program. Once enrolled, families will receive a member handbook explaining the health plan benefits and can contact the numbers below for information regarding the health plans.

Amerigroup : 1-800-600-4441

Health Plan of Nevada : 1-800-962-8074

For families living in the Fee-For-Service benefit area, services may be obtained from any Nevada Medicaid provider who will accept Nevada Check Up. If you need assistance in locating a provider, please call your local Medicaid District Office:

Carson City (775) 684-3653 Reno (775) 688-2811 Las Vegas (702) 486-1550 Elko (775) 753-1191

Third Party Liability

A condition of being eligible for Nevada Check Up is the agreement to assign all rights to any medical claims, medical support or other payments for medical care. Recipients must cooperate with the division in obtaining payments for medical care from any third party or person who may be liable for the medical services paid for by the Nevada Check Up Program. Recipients must inform Nevada Check Up if any legal action is taken against anyone or if any offer or settlement is received for the reimbursement of medical care and treatment that may be paid for by the Nevada Check Up Program.

Investigations and Referrals

Information provided to NCU may be verified or investigated by federal, state and local officials. If you do not cooperate in the investigation, which may include a home visit, your benefits will be denied or terminated. If you make false or misleading statements, misrepresent, conceal or withhold facts; or alter any document necessary to make an accurate eligibility determination, your benefits may be denied or terminated. You are responsible for repayment of all monies paid for services to which you were not entitled and you may be subject to any criminal and/or civil penalties in accordance with state and federal law.

ADDITIONAL DOCUMENTATION NEEDED FOR A COMPLETE APPLICATION:

Employed

Proof of income - two current and consecutive pay stubs (not more than 45 days old from application date) *If paycheck stubs are not available you need to contact Nevada Check Up for an Earnings Verification Form

Unemployed

Current unemployment award letter if receiving unemployment benefits

Self-employed

Complete copy of last year’s tax return

Last 3 months of personal and business bank statements

Other Income

Current year award letter for RSDI, SSI, Worker’s Compensation, VA Benefits, Disability Benefits, Pension Payments, interest/dividends received, proof of money from property (rent received) and proof of any other income not listed

Proof of child support including amount and frequency per child if applicable

Page 6 of 6

PLEASE KEEP FOR YOUR RECORDS

NCU App Insert English (06/10)

Form Specs

Fact Detail
Program Name Nevada Check Up (NCU)
Type of Program Children’s Health Insurance Program (CHIP)
Governing Law(s) NRS 53.045, NRS 199.120 thru NRS 199.200, NRS 41.365, applicable federal laws
Contact Information 1-877-KIDS NOW (543-7669), Fax: (775) 684-8792
Eligibility Children through 18 years of age, not covered by Medicaid, without health care coverage or uninsured for the last six months, not eligible for PEBP, meet federal income guidelines (200% FPL or below)
Health Services Covered Comprehensive medical, dental, and medical vision care
Premium Payments Quarterly premiums determined by family size and income. Premiums charged per family, not per child. Amounts range from $25 to $80.

How to Fill Out Nevada Check Up

Filling out the Nevada Check Up form is a crucial step in securing affordable health care for eligible children within the state. This program aims to provide comprehensive medical, dental, and vision care for children who don't have access to other forms of health insurance. To ensure a smooth application process, carefully follow the steps outlined below to complete the form correctly. Ensure all information provided is accurate to avoid any delays in the review or approval process.

  1. Start by determining whether you would like your application to be referred to Nevada Medicaid if applicable by checking either "Yes" or "No".
  2. Indicate whether you are currently applying for Medicaid medical assistance for any listed individuals by selecting "Yes" or "No".
  3. Complete the section titled "Person or Head of the Household Applying for Child(ren)": enter the applicant's last name, first name, middle initial, Social Security Number, date of birth, marital status, race/ethnicity (optional), citizenship status, preferred language, and contact information. Specify the home address, mailing address (if different), phone numbers, and household size. Confirm if the household will continue living in Nevada, and if your rent or mortgage is subsidized by an agency.
  4. List all adults in the household, providing their last name, first name, middle initial, Social Security Number, date of birth, marital status, race/ethnicity (optional), citizenship status, and their relationship to the applicant.
  5. For each child in the household, fill out the required sections with their last name, first name, middle initial, Social Security Number, date of birth, marital status (optional), race/ethnicity (optional), citizenship status, pregnancy status, whether you are applying for NCU for this child, disability status, health insurance information, parental relationship, and child care expenses if applicable.
  6. Enter employment information for each adult residing in the household, including name, employer's name and address, employer's phone number, gross pay, tips, and pay frequency.
  7. Under "Other Income", list all types of income received by anyone in the household, the name of the recipient, amount, and how often it is paid. Leave blank if not applicable.
  8. Select a health plan from the options provided or note that you would like the program to choose one for you if you don't have a preference.
  9. Indicate how you heard about Nevada Check Up by checking the appropriate box.
  10. The last step is to sign the form, affirming that all the information provided is accurate and you agree to report any status changes. Include the date next to your signature.

Once completed, send your application to the Nevada Check Up Program office in Carson City. The address and contact information are provided on the form. Remember, the review process may take up to 45 days, especially if all required documentation is submitted correctly and on time. Stay informed about the status of your application, and don't hesitate to follow up if necessary.

Obtain Clarifications on Nevada Check Up

FAQ: Nevada Check Up (NCU) Application

  1. What is Nevada Check Up?

    Nevada Check Up is the Children's Health Insurance Program (CHIP) in Nevada. It offers low-cost health care coverage to uninsured children under 19 years old who meet specific requirements. The service includes medical, dental, and vision care.

  2. Who can apply for Nevada Check Up?

    Children under the age of 19 who do not have health insurance and are not eligible for Medicaid can apply. They must also not have been covered by insurance in the last six months, not have access to insurance through the Public Employee Benefits Program, and meet the program's income requirements.

  3. How does applying for Nevada Check Up affect immigration status?

    Applying for Nevada Check Up does not affect an applicant's immigration status or their family's. The program is available to U.S. citizens and Lawful Permanent Residents (LPR) who have been in that status for five years.

  4. How are applicants evaluated for Nevada Check Up eligibility?

    Eligibility is based on several factors including residency in Nevada, age, lack of other health coverage, and family income level. Income guidelines are set at 200% of the Federal Poverty Level (FPL), but those above this may still qualify in the future as FPL standards can change.

  5. Is there a cost to participate in Nevada Check Up?

    Yes, there is a quarterly premium based on the family's size and income. This premium is per family, not per child, and the amount is determined upon enrollment. However, American Indian families part of federally recognized tribes may have their premiums waived.

  6. What if I have an unpaid premium from a previous enrollment?

    Children will not be re-enrolled in Nevada Check Up until all outstanding premiums are paid. Payment arrangements are available and must be completed within 60 days. Failure to pay premiums will result in disenrollment from the program.

  7. How do I apply or send correspondence for Nevada Check Up?

    Applications and any other correspondence can be sent to the Nevada Check Up Program at 1000 E. William Street, Suite 200, Carson City, NV 89701. Assistance is available by calling (775) 684-3777 or toll-free at 1-877-KIDS-NOW (543-7669). Spanish speaking staff and more information are also available on the website.

Common mistakes

When individuals in Nevada set out to fill the Nevada Check Up (NCU) form for the Children’s Health Insurance Program (CHIP), they aim to secure health coverage for children in their households. Despite the straightforward nature of this process, several common mistakes can complicate or delay the application. Understanding and avoiding these errors can ensure a smoother path to obtaining necessary health benefits.

First and foremost, a frequent oversight is not providing complete information about the person or head of the household applying for child(ren). Essential details such as the Social Security Number, citizenship status, and contact information are critical for the processing of the application. A failure to thoroughly complete this section can lead to unnecessary delays.

Another significant error is related to the listing of all adults in the household. The form requires information on all adults, regardless of their relationship to the child. Often, applicants omit roommates or extended family members living in the household, not recognizing their relevance. However, this information could affect the eligibility and premium calculations for the CHIP program.

  1. Neglecting to check or incorrectly answering whether the application should be referred to Nevada Medicaid if applicable. This oversight can prevent children who might not qualify for NCU but are eligible for Medicaid from receiving timely benefits.
  2. Incorrectly reporting employment information and other income. Complete and accurate income information is crucial for assessing eligibility. Applicants must include all sources of income, such as child support, Social Security payments, or unemployment benefits, to ensure accurate processing.
  3. Failing to declare or misunderstanding questions about current health insurance coverage or eligibility for other programs. For children currently covered by Medicaid or another insurance, applicants might mistakenly believe they are ineligible for NCU. This confusion can lead to missed opportunities for additional or more suitable coverage.
  4. Omitting or inaccurately reporting child care expenses. For families that incur child care costs, accurately reporting these expenses can significantly influence eligibility and the benefit amount.
  5. Lastly, many applicants overlook the importance of choosing a health plan or do not realize that they can select one on the application. If left unselected, NCU will assign a plan, possibly missing an opportunity to choose the most appropriate coverage for the children's needs.

In conclusion, while filling out the Nevada Check Up form might seem straightforward, paying attention to detail and providing complete and accurate information is paramount. Applicants must thoroughly review their applications for mistakes related to household information, income reporting, and health coverage options to ensure a smooth and timely approval process. By avoiding these common errors, families can more easily navigate the path to securing essential health benefits for their children.

Documents used along the form

When completing the Nevada Check Up form, applicants may need to gather additional documents and forms to support their application. This process ensures that all necessary information is accurately conveyed for the eligibility review. Below is a list of other forms and documents often used along with the Nevada Check Up form.

  • Proof of Income Documentation: Pay stubs, tax returns, or letters from employers are used to verify the income of the household members.
  • Proof of Citizenship or Legal Residency: Birth certificates, passports, or green cards help confirm the citizenship status or legal residency of the applicant and children.
  • Social Security Numbers: Copies of Social Security cards for each applicant provide verification of their Social Security numbers.
  • Proof of Nevada Residency: Utility bills, lease agreements, or mortgage statements confirm the applicant’s residence within the state of Nevada.
  • Proof of Child Care Expenses: Receipts or statements from child care providers verify the costs associated with child care, which may affect eligibility.
  • Health Insurance Information: Documents or cards related to current or previous health insurance coverages provide details on the insurance status of the children.
  • Medical Records for Disabled Children: If applying for a child with disabilities, medical records or documentation from health care providers support the child's condition.
  • Proof of Other Insurance Denials: Letters or notices from other health insurance providers, including Medicaid denials, can be necessary if the child was previously insured or applied for other coverage.
  • Child Support or Alimony Documentation: Court orders or payment receipts help verify income from child support or alimony, affecting the overall household income assessment.

Gathering these documents in advance can simplify the application process, allowing for a more seamless review. Responsible preparation ensures that all information provided is complete and accurate, fostering a smooth path toward determining eligibility for the Nevada Check Up program. If questions arise during the application process, assistance is readily available through the Nevada Check Up contact information provided on the application form.

Similar forms

The Nevada Check Up form is similar to various other application forms utilized within the United States to apply for public assistance and healthcare programs. Specifically, it bears resemblance to applications for Medicaid and the Children's Health Insurance Program (CHIP) at both federal and state levels. Each of these applications typically requires detailed personal information, including household composition, income details, and citizenship status. Additionally, they all aim to assess the eligibility of applicants for health care benefits based on a set of predefined criteria. Like the Nevada Check Up form, Medicaid and CHIP applications often inquire about current health coverage, aiming to identify the most appropriate program for each applicant and avoid overlaps in coverage.

Another document closely related to the Nevada Check Up form is the application for the Supplemental Nutrition Assistance Program (SNAP). Although SNAP is primarily focused on providing nutritional assistance rather than health coverage, the application processes share several key features. For instance, both require applicants to provide comprehensive information about their household's financial situation, including income, employment, and other resources, to determine eligibility. They also ask for detailed demographics of every household member. Despite the different benefits they offer, the underlying goal of these forms is to evaluate whether applicants meet the specific threshold requirements set by each program.

Dos and Don'ts

When it comes to filling out the Nevada Check Up form, making sure everything is completed correctly is crucial for a smooth process. Here are some tips on what you should and shouldn't do:

  • Do fill in all requested information accurately. Inaccurate information can delay the process.
  • Do provide a copy of the birth certificates for the children if they are available, as requested in the form.
  • Do select a health plan or understand that if you don't choose one, a plan will be chosen for you.
  • Do sign the application. Without your signature, the application cannot be processed.
  • Do Not leave sections blank. If a section doesn't apply to you, make sure to mark it as N/A.
  • Do Not forget to list employment information for each adult living in the household and provide income verification as instructed.
  • Do Not provide false or misleading information. This can result in denial of benefits or even legal consequences.

Remember, the details you provide are crucial for assessing your eligibility for the Nevada Check Up program. Accuracy and completeness can significantly impact the review process and outcomes of your application.

Misconceptions

Misconceptions about the Nevada Check Up (NCU) form and its processes can lead to confusion or hesitancy among potential applicants. Below is a list of common misconceptions corrected for clarity.

  • Nevada Check Up is only for children with U.S. citizenship. While the form requires information on citizenship status, children who are Lawful Permanent Residents (LPR) for five years also qualify. The program aims to provide low-cost health care to uninsured children, regardless of their citizenship, as long as other eligibility criteria are met.
  • Applying for Nevada Check Up will affect my family’s immigration status. The application process for NCU is designed to protect the applicant's confidentiality and immigration status. Applying for Nevada Check Up will not affect the family’s immigration status, as noted in the guidelines provided with the application form.
  • If a child is eligible for Medicaid, they cannot apply for Nevada Check Up. The application form clearly states that if it appears children may be eligible for Medicaid, NCU enrollment will be denied and the case may be referred for a Medicaid eligibility review. This integration ensures that children receive the most comprehensive coverage available to them, but it does not prevent one from applying for NCU.
  • Premium payments are per child. Actually, the quarterly premium for Nevada Check Up is charged per family, not per child, which is a common misunderstanding. The form clarifies that the premium amount depends on family size and income, making the program affordable for families with multiple children.
  • All health services are covered by Nevada Check Up. While Nevada Check Up provides comprehensive medical, dental, and medical vision care, it covers "most medically necessary services" as specified in the documentation. This implies that there might be certain limits or exceptions to coverage, emphasizing the importance of reviewing the specifics of covered services.
  • The eligibility determination process is immediate. As outlined in the application, the determination process for eligibility can take up to 45 days, starting when a complete application with all necessary, requested, and required documentation is received. Understanding this timeline helps manage expectations regarding the start of coverage and premium notifications.

Clearing up these misconceptions ensures that families have accurate information when considering Nevada Check Up for their children's health care needs. This contributes to informed decisions about applying for and participating in the program.

Key takeaways

Understanding the Nevada Check Up form is crucial for ensuring that eligible children access the comprehensive medical, dental, and vision care they need. Here are ten key takeaways to guide you through the application process:

  • Eligibility for the Nevada Check Up (NCU), the state's Children's Health Insurance Program (CHIP), is primarily determined by income, with the threshold set at 200% of the Federal Poverty Level (FPL).
  • Children must be under 19 years of age, not covered or eligible for Medicaid, without health insurance for the last six months, and not have access to the Public Employee Benefits Program (PEBP).
  • Applying to NCU will not negatively impact your family's immigration status, encouraging families of all backgrounds to apply if they meet other eligibility criteria.
  • Applications can be referred to Nevada Medicaid for eligibility review if it seems that the children might qualify, offering a streamlined process for accessing health coverage.
  • The application requires detailed information about each household member, including children for whom NCU coverage is sought, emphasizing the need for accurate and complete submissions.
  • Proof of income is necessary to process the application, with specific documentation required to verify the earnings of each adult in the household.
  • The cost associated with NCU is a quarterly premium, based on family size and income, making the program affordable for qualifying families.
  • Failure to pay premiums results in disenrollment, highlighting the importance of maintaining regular premium payments once enrolled.
  • Applicants must immediately report any changes in their children’s eligibility status, such as gaining Medicaid coverage or moving out of state, ensuring that NCU records accurately reflect current circumstances.
  • The NCU application includes an affirmation section where the applicant must certify the accuracy of the information provided and agree to the terms of participation, underscoring the legal responsibilities involved in applying.

Filling out the Nevada Check Up form attentively and accurately is the first step toward securing essential health services for children who need them. With an understanding of these key points, applicants can navigate the process more effectively, ensuring that no child in Nevada goes without necessary medical care.

Please rate Fill Out a Valid Nevada Check Up Template Form
4.75
First-rate
225 Votes