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GOVERMENT OF PUERTO RICO Department of Health - PR

GOVERMENT OF PUERTO RICO Department of Health - PR 2026

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The document is a form from the Department of Health's Medicaid Program requesting income verification from an employer for an individual applying for Medicaid benefits. It includes sections for the employer to provide details about the employee's job status, hours worked, and income over the past four months. The document emphasizes confidentiality and warns against providing false information, which could lead to legal consequences.

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Click ‘Get Form’ to open it in the editor.
Begin by entering the date at the top of the form. This is essential for record-keeping.
In the 'Nombre de la Compañía' section, input the name of the company employing the individual seeking Medicaid benefits.
Fill out the employee's work status by selecting either 'Tiempo Completo' or 'Tiempo Parcial'.
Provide details about total weekly hours worked and the employee's position within the company.
Indicate how long the employee has been with your company, as this information is crucial for eligibility assessment.
Complete the income section by detailing current and past monthly earnings, including gross salary, tips, bonuses, and commissions.
Finally, ensure that all fields are filled accurately before signing and dating at the bottom of the form.

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