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Thank you for your interest in IEHP Healthy Kids.
Based on the information you gave me on the phone, your children qualifY for the program. All you
have to do now is finish your application, and send us proof of your income, proof that you live in
San Bernardino County, and your $20 application fee.
It's important that you return this package to us as soon as possible. We can only take a limited
number of children and I don't want you to miss out.
Enclosed with your application is an instruction sheet called "Finishing Up Your Application." It will
help you put your application package together. On the back of that sheet is a list of the documents
you need to send us. Make sure you send everything I've checked off so your application doesn't get
held up.
Please review the application carefully to see if everything I wrote is correct. If any information needs
to be changed, go ahead and make the change. Also, don't forget to sign your application before
sending it back to us.
If nothing has changed from what we discussed on the phone, it will take about 10 days to approve
your application after we receive it. Your children's insurance will go into effect 10 days from the
time you are approved.
If program funds run out before you're approved, your family will be put on a waiting list.. .so please
don't delay. And if you have any questions, don't hesitate to call us at 1-866-294-IEHP (4347) /
TDHI 909-890-0731.
Thank you and good luck.
IEHP Enrollment Assistant
P.O. Box 19026. Son Bernardino. CA 92423-9026
Tel (909) 890-2000 Fox (909) 890-2003
Visit our website at: www.iehp.org
A Public Entity
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Finishing Up Your Application
I. Make copies of required documents. lEHP requires that you submit documents that
support the information you put on your application. See the list on the bottom of this page. [ have indicated
which documents you need to submit back to lEHP. Never send originals.
2. Review your application carefully. Make sure all the information is correct and sign the application.
3. Prepare your package for mailing. Make sure you have included copies of all the
documents. the signed application, and your Healthy Kids Application Fee payment. You will find a postage-paid
envelope addressed to IEHP in the application booklet.
4. For more information about IEHP, feel free to call us at 1-866-294-IEHP (4347)
Documents You Need To Send Us
Make copies ofthe "checked" documents below. Never send originals
Proof of Residencv
o
o
County Residency-Must show residency for the last 3 months
RENTAL AGREEMENT/LETTER PLUS 3 MONTHS OF RECEIPTS: With name, date of rental start date,
address of rental, and 3 rental receipts for , 2003, with the name, month
of rent, and address on each receipt
o STUDENT DATA FOR.;.v[: Must include' child's name, date of birth, home address, home phone #, parent's
name and address, school's name and address, and the most important the original date of entry in the school
system
o THREE UTILITY BILLS: Three utility receipts for the months of
, 2003 must include name, month, and home address
o OTHER:
Proof of Income
o Pay Stub(s)
o Employer Letter/Statement (Gross monthly income and dates received)
o Letter stating you and/or your spouse have no income
o Federal Income Tax Return
o Retirement/Disability Income (award letters or statements showing direct deposit)
o Social Security
o Disability
o Child Support/Alimony Incomc
Copy of check/money order received or statement from payer, plus copy of the Court Order, if
available
o Self-Employed Income:
o Federal Income Tax Returns with Schedule C
o Profit and Loss statements for the last 3 months
Proof of Deductions
o Child Support/Alimony Expense
Copy of cancelled check/money order receipt or statement from payee, plus copy of Court Order, if
available.
o Child Care/Dependent Care: Receipts or cancelled checks or written statement
o Proof of Preg1l':1ncy
From a doctor or clinic
Pavment
o Make money order payable to IEHP or please complete the credit card information on your application
(Checks not accepted)
For Help, Call Toll Free, ]-866-294-IEHP (4347)
---~.~
The person applying for the child must be a parent, legal guardian, stepparent, foster parent
a or caretaker relative. Please complete boxes 1-7 for the person applying.
b Tell us about the child{ren) under age 19 who need coverage
Complete boxes 8 - 13 for each child. To add more children,
use a separate piece of paper or a photocopy of page I of the application.
#8 Please print the name of each child.
#9 Please put the date of birth for each child.
#10 Please put the sex of each child.
#11 Social Security numbers are NOT required for Healthy Kids.
#12 Please put how each child is related to the person making this application?
For example: daughter, stepchild, nephew, etc.
#13 Please add your ethnicity in this box. This box is optional for Healthy Kids.
White
Hispanic
Black/African American
Asian
Native American Indian
Filipino
Amerasian
Chinese
Cambodian
Japanese
Korean
Samoan
Asian Indian
Guamanian
Laotian
Vietnamese
Other
#14 - 16 Please choose a Doctor. With IEHP, you have a choice of more than
600 Doctors. If you do not choose a Doctor yourself, IEHP will choose
a Doctor for you.
You must write the Doctor's Name in Box #14 and the Doctor's Number in Box #15. You will
find each Doctor and their Doctor Number listed in the IEHP Provider Directory included
with this Application.
For Help, Call Toll Free;1-866-294-IEHP (4347)
IMPORTANT!
. Your Application Fee will be $20 for the entire family.
C Gross Income (before taxes)
List the gross income of all parents or guardians who live in the home of the child(ren) being
applied for. This information is used to determine eligibility for Healthy Kids.
#17 Use a separate line for each parent or guardian of the child(ren) being applied for who
receives income. If a person gets income from two different sources, use two lines.
For example: If you have two jobs, use one line for each job to report earnings.
#18
Job
Child Support
Alimony
Social Security
Gifts
An Employer or Self-Employed
A Parent who does not live in the home
Court Ordered or Voluntary Income from an ex-spouse
Survivor's Benefits
Relatives, Friends. etc.
#19 How often is this income received? For example:
Weekly
Every 2 weeks (26 Paychecks a Year)
Twice a Month (24 Paychecks a Year)
Once a Month
#20 V\'hat is the Gross Amount?
For example: if the income is received once a week, write the weekly amount in the box
If the income amounts change from time to time, put the average amount (before'
taxes) received on a regular basis. We will use the pay stub or other document you
give us to figure out the correct monthly income.
If self-employed, write the net profit from Schedule C (Line items 22 on the 1040, 13
and 24 from your Schedule C, add these numbers and divide by 12 months) of last
year's federal income tax return, or provide the last 3 months' profit and loss state-
n1ents.
If using last year's federal income tax return, add all income amounts reported.
Do NOT deduct losses.
For Help, Call Toll Free, 1-866-294-IEHP (4347)
#21- 22 Deductions from Family Income
The answers in this section will help determine what amounts will be deducted from
your family's gross monthly income for calculating Healthy Kids eligibility.
d Federal Income Guidelines
1
2
3
4
5
6
7
8
9
10
$2,246.40
$3,031.20
$3,817.20
$4,602.00
$5,386.80
$6,171.60
$6,956.40
$7,741.20
$8,527.20
$9,312.00
Income per F..deral Powr'y ul'cl4/OJ/2003
lEHP will use these Federal Income Guidelines to determine if your Monthly Family Income
qualifies you for the Healthy Kids Program.
Note on Family Size
Family size is used to determine eligibility for Healthy Kids. An unborn child; all children
under age 2] living in the home; all children under age 21 a",ay at school and claimed as tax
dependents will be included. IEHP does not count family members who receive public assis-
tance such as SSl/SSP or CaIWORKS.
For Help, Call Toll Free, 1-866-294-IEHP (4347)