The Nevada Check Up form is an application for the state's Children's Health Insurance Program (CHIP), designed to provide affordable health coverage for uninsured children under 19 years old. This form collects essential information about the household, including details about the adults and children living there. Completing the form accurately is crucial to ensure your children receive the health benefits they need.
To get started, fill out the Nevada Check Up form by clicking the button below.
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)
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:
Male
Female
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
Lawful Permanent Resident (LPR) as of
(Date):
Relationship to applicant above
Spouse Sibling Child Parent Other Relative Other :
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NCU-0100 (06/10)
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.
Social Security # (REQUIRED)
(REQUIRED)
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?
Yes
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
Major Medical
Medicare A, B, or D
Step-Child
None
Niece/Nephew
Child Care Expenses - complete if applicable
Amount Paid:
How often paid:
disabled and
receiving SSI?
Yes, Name of Insurance:
Cancer Dental/Vision
Relationship of child to applicant:
(3) Last Name
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(4) Last Name
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
(2) Person Employed - Last, First
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
Amount
Child Support/Alimony
Social Security Payments - select
RSDI
SSI
Disability Payment Source
Unemployment Benefits
Pension Payment and Source
Interest or Dividends (Stocks, Bonds,
Trusts, Mutual Funds, Savings, etc.)
Other (such as cash assistance, etc)
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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
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:
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.
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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
Apr, May, Jun
4th Quarter
July 1
Jul, Aug, Sept
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PLEASE KEEP FOR YOUR RECORDS
NCU App Insert English (06/10)
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
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After completing the Nevada Check Up form, the application will be reviewed to determine eligibility for health coverage. If your children qualify for Medicaid, the application for Nevada Check Up may be denied, and your case could be referred for further review. It’s essential to ensure all information is accurate and complete to avoid delays in processing.
How to Get My Edrs Number - The form must be accurately filled out to avoid processing delays.
The California Release of Liability form is a legal document that helps protect individuals and organizations from being held responsible for injuries or damages that may occur during certain activities. Typically used in recreational settings or events, this form outlines the risks involved and requires participants to acknowledge and accept those risks. Understanding this form is crucial for anyone seeking to participate in activities where liability concerns may arise, and resources such as fastpdftemplates.com can provide valuable assistance in drafting this important document.
Reg 5045 - It is important to review the form for any missing information before submission.
Nevada Check Up is the state's Children's Health Insurance Program (CHIP). It provides low-cost health care coverage to uninsured children from birth through 18 years of age, as long as they meet specific program guidelines. The program is funded by both federal and state resources.
What health services are covered under Nevada Check Up?
Most medically necessary services are covered. This includes comprehensive medical care, dental care, and vision care for children. The aim is to ensure children receive essential health services.
To qualify for Nevada Check Up, children must not be covered by Medicaid or any other health insurance. They should also not have had insurance in the last six months. Additionally, applicants must be U.S. citizens or Lawful Permanent Residents for at least five years. Income must be within 200% of the Federal Poverty Level, and children must be under 18 years and 11 months at the time of application.
How much are the premium payments for Nevada Check Up?
The only cost associated with Nevada Check Up is a quarterly premium, which is based on family size and income. The premium is charged per family, not per child. For example, premiums range from $25 to $80 depending on the family's income level. American Indian families may have their premiums waived with proof of tribal affiliation.
What happens if my child was previously enrolled and has an unpaid premium balance?
If your child was previously on Nevada Check Up and has an unpaid premium balance, they will not be enrolled until the payment is received. Payment arrangements can be made, but they should not exceed 60 days. It's important to address any outstanding balances to ensure continued coverage.
How long does the eligibility determination process take?
The eligibility determination process may take up to 45 days. This period begins when a complete application, along with all necessary documentation, is received. Families will be notified by mail regarding the start date of coverage and the premium amount once approved.
Can I request a hearing if my application is denied?
Yes, if your application is denied or if you disagree with any decision made by Nevada Check Up, you have the right to request a hearing. This request must be submitted in writing within 30 days of receiving the denial letter.
How can I contact Nevada Check Up for assistance?
If you have questions regarding the Nevada Check Up application or need assistance, you can call 1-877-KIDS NOW (543-7669). Spanish-speaking staff is available to help. Additional information can also be found on the Nevada Check Up website.
What should I do if my household information changes?
It is important to report any changes in your household information immediately. This includes changes in address, phone number, household members, or if any child becomes eligible for Medicaid or other health insurance. Prompt reporting helps maintain accurate records and coverage.
Incomplete Information: Many applicants fail to provide all required details. This includes missing Social Security numbers, dates of birth, or marital status for both adults and children. Omitting these essential pieces of information can delay processing or result in application denial.
Incorrect Household Composition: Some applicants do not list all adults and children living in the household. It's crucial to include everyone, regardless of their relationship to the child applying for coverage. Missing individuals may lead to inaccuracies in income assessment and eligibility determination.
Failure to Report Other Income: Applicants often neglect to disclose all sources of income. This includes child support, alimony, or any other financial support. Not reporting this information can affect eligibility and may result in penalties if discovered later.
Not Following Up on Application Status: After submitting the application, some individuals do not check on its status. This can lead to missed communications or notifications regarding additional information needed or eligibility determinations. It is important to stay proactive in ensuring the application is processed smoothly.
The Nevada Check Up form is a crucial document for families seeking health insurance coverage for their children through the state’s Children’s Health Insurance Program (CHIP). However, several other forms and documents are often used in conjunction with this application to ensure a comprehensive review of eligibility and benefits. Below is a list of these related documents, along with a brief description of each.
Gathering these documents can streamline the application process and ensure that families receive the appropriate health coverage for their children. Each document plays a role in verifying eligibility and ensuring compliance with program guidelines, ultimately helping to secure the necessary health care services.
Medicaid Application Form: Similar to the Nevada Check Up form, the Medicaid application collects personal information about the applicant and household members. Both forms inquire about income, household size, and citizenship status to determine eligibility for health coverage.
Children’s Health Insurance Program (CHIP) Application: Like the Nevada Check Up form, the CHIP application is designed to provide health insurance for children from low-income families. Both documents require details about household members and their health insurance status.
Food Assistance Application: This application gathers information about household income and size, similar to the Nevada Check Up form. Both forms aim to assess eligibility for government assistance programs.
Temporary Assistance for Needy Families (TANF) Application: The TANF application, like the Nevada Check Up form, requires personal details and income information to evaluate eligibility for financial assistance for families in need.
WIC Application: The Women, Infants, and Children (WIC) program application asks for information about household income and family size, similar to the Nevada Check Up form. Both forms support families in accessing essential health and nutrition services.
Housing Assistance Application: This application collects data on household composition and income, paralleling the Nevada Check Up form. Both documents are used to determine eligibility for government assistance programs.
Unemployment Benefits Application: The application for unemployment benefits requires information about previous employment and household income, akin to the Nevada Check Up form. Both forms help assess the financial needs of applicants.
Health Insurance Marketplace Application: Similar to the Nevada Check Up form, the Health Insurance Marketplace application gathers personal and financial information to evaluate eligibility for health insurance plans under the Affordable Care Act.
Social Security Disability Benefits Application: This application requires detailed information about the applicant's medical condition and financial situation, much like the Nevada Check Up form. Both forms are essential for determining eligibility for support.
Tax Credit Application for Health Insurance: The application for tax credits related to health insurance coverage collects income and household size information, similar to the Nevada Check Up form. Both forms are designed to help individuals access affordable health care.