Other Forms of Documentation
Tier 2 Documents (proof of citizenship only)
- A U.S. public birth record issued before the person was five years of age
- Certification of Report of Birth
- Certification of Birth Abroad
- U.S. Citizen ID Card (issued by what was formerly the Immigration and Naturalization Service—INS)
- Consular Report of Birth Abroad of a U.S. Citizen
- American Indian card with code KIC
- Issued by the Department of Homeland Security (DHS) to a member of the Texas Band of Kickapoos living near the U.S.-Mexican border
- Northern Mariana Card
- Issued by the former INS to a collectively naturalized citizen of the U.S. who was born in the Northern Mariana Islands before November 4, 1986
- Final adoption decree
- Evidence of U.S. civil service employment before June 1, 1976
- Official military service record that shows U.S. place of birth
Tier 3 Documents (proof of citizenship only)
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NOTE: To use documents from Tier 3 or Tier 4, an individual must prove that he or she lacks documents from the higher tiers, cannot obtain them within a “reasonable opportunity period” (generally around 45 days) set by the state, and assert that he or she was born in the United States. |
- Extract of hospital record on hospital letterhead established at time of person’s birth and created at least five years before the initial application date
- Life or health insurance record created at least five years before the date of Medicaid application showing U.S. place of birth
- Religious records, such as a baptismal certificate, recorded in the United States within three months of birth
- Early school records showing a U.S. place of birth
Tier 4 Documents (proof of citizenship only)
| NOTE: To use documents from Tier 3 or Tier 4, an individual must prove that he or she lacks documents from the higher tiers, cannot obtain them within a “reasonable opportunity period” (generally around 45 days) set by the state, and assert that he or she was born in the United States. |
- Federal or state Census record showing age and U.S. place of birth
- For people born between 1900 and 1950, the applicant, recipient, or state should complete a Form BC-600, Application for Search of Census Records for Proof of Age
- Roll of Alaska Natives maintained by the Bureau of Indian Affairs
The following Tier 4 documents must have been created at least five years before the date of the Medicaid application:
- Seneca Indian tribal Census record
- Bureau of Indian Affairs (BIA) tribal Census records of the Navajo Indians
- U.S. state vital statistics official notification of birth
- Amended U.S. public birth record
- Statement signed by physician/midwife in attendance at birth
- Institutional admission papers indicating place of birth
- Medical record indicating U.S. place of birth
In rare circumstances:
- Written affidavit from at least two individuals, signed under penalty of perjury (but need not be notarized)
- At least one individual must be unrelated to the applicant/recipient
- Both individuals must have personal knowledge of the events establishing the applicant’s or recipient’s claim of citizenship
- The individuals making the affidavit must be able to provide proof of their own citizenship and identity.
The applicant, recipient, or other knowledgeable individual must provide a second affidavit explaining why documentary evidence does not exist or cannot be readily obtained.
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