Montgomery County Care Enrollment Form

Montgomery County Care
c/o CareSource
P.O. Box 1408
Dayton, OH 45401

At this time, Montgomery County Care is only accepting renewal applications. To re-enroll in Montgomery County Care, please provide the following information

Montgomery County Residents Only

 
* Required
* Required
  * Required
  * Required
* Required

  * Required Example: ###-###-####
  Example: ###-###-####
  Example: name@gmail.com
Permanent Residence:
 
* Required
* Required
* Required  
 
  * Required
Mailing Address:
(only if different from your Permanent Residence Address)
 
Emergency Contact:
 
  Example: ###-###-####

Please Complete the Section Below Only if You are Filling Out the Application for Another Person


  Example: ###-###-####

Applicant’s Personal Information

* Required







* Required
if yes,
 
 
 
 
* Required
If yes,
please list the insurance carrier’s name below and check all that apply




 
 
* Required
if no,
 

 
 
* Required
* Required
if yes,
 

Applicant’s Employment Information

* Required
if yes,
please provide the following information
  Example: ###-###-####
(indicate weekly, monthly, or yearly)
 
 
  Example: ###-###-####
(indicate weekly, monthly, or yearly)
 
 
  Example: ###-###-####
(indicate weekly, monthly, or yearly)
 
 

Applicant’s Household Information


* Required
* Required
* Required
* Required
if yes,
 

Please list the names and ages of dependent children:

 
 
 
 
* Required

Note: Eligibility for the Montgomery County Care Program is determined based on household income.

Please Read The Important Information Below Before Completing This Enrollment Form

A limited number of enrollees will be accepted into the Montgomery County Care program. Applications received and approved after the allotted number of enrollees have been accepted, will be held and placed on a waiting list for up to three months.

I have read this application in its entirety and certify the information is accurate and complete. I understand and agree that any false statements or omissions may void any benefits received as a result of this application. I further understand a person who submits an application or files a claim with intent to defraud or helps commit a fraud is guilty of a crime. I understand that any entity(s) with which I am applying for benefits reserves the right to accept or decline this application in whole or in part.

I hereby authorize the release of my protected health information to CareSource and Montgomery County, Ohio, for purposes of treatment, payment, or health care operations or any other purpose permitted under state and federal laws or regulations. "Protected health information", "treatment", "payment" and "health care operations" shall have the meanings as set forth at 45 CFR 160.103 and 164.501.

Signature:

 Today's Date:   * Required * Required
Type name and date to authorize

If you are the authorized representative please place your name in the box above, and complete the following information:

  Example: ###-###-####