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- Click ‘Get Form’ to open the positive pregnancy report PDF in the editor.
- Begin with Section 1: Applicant Information. Fill in your full name, address, phone number, date of birth, and county of residence. Ensure all details are accurate for proper processing.
- In Section 2: Health Insurance, indicate if you have applied for Medicaid or Cash Assistance within the last three months. If applicable, provide details about any private health insurance coverage.
- Proceed to Section 3: Family Size. Count yourself as one and include any dependents living with you. Calculate the total family size accurately.
- For Section 4: Income, enter your gross monthly income if you are over 21. Be sure to exclude any non-countable income sources as specified.
- In Section 5: Presumptive Eligibility Determination, compare your income against the Federal Poverty Level guidelines and indicate eligibility status.
- Finally, complete Section 6: Provider/Screener Information by entering the screener's name and signature along with their contact details.
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