Level 3 and 4 list

To be used if no other citizenship documents are available

17. Extract of hospital record on hospital letterhead established at the time of the person’s birth and created at least 5 years before the initial application date and indicating a U.S. place of birth
18. Life or health or other insurance record showing a U.S. place of birth and created at least 5 years before the initial application date
19. Federal or state census record showing U.S. citizenship or a U.S. place of birth (Generally for persons born 1900 through 1950)
20. Any of the following documents that were created at least 5 years before the application for Medicaid:
    1. Seneca Indian tribal census record
    2. Bureau of Indian Affairs tribal census records of the Navaho Indians
    3. U.S. State Vital Statistics official notification of birth registration
    4. Amended U.S. public birth record that is amended more than 5 years after the person’s birth
    5. Statement signed by the physician or midwife who was in attendance at the time of birth
21. Institutional admission papers from a nursing home, skilled nursing care facility or other institution which were created at least 5 years before the initial application date and indicating a U.S. place of birth
22. Medical (clinic, doctor, or hospital) record which was created at least 5 years before the initial application date and indicating a U.S. place of birth
23. Written Affidavit.  Affidavits should ONLY be used in rare circumstances.  An affidavit by at least 2 individuals of whom one is not related to the applicant/recipient and who have personal knowledge of the event establishing the applicant’s or recipient’s claim of citizenship.  The person(s) making the affidavit must be able to provide proof of his/her own citizenship and identity for the affidavit to be accepted.  If the affiant has information which explains why documentary evidence establishing the applicant’s claim of citizenship does not exist or cannot be readily obtained, the affidavit should contain this information as well.  It must also be signed under penalty of perjury by the person making the affidavit.  A second affidavit from the applicant/recipient or other knowledgeable individual explaining why documentary evidence does not exist or cannot be readily obtained must also be requested.

{8/20/07}