nia Call Centeer
Cover Virgin
Script: Rig
ghts & Respo
onsibilities, C
Consent & Pla
an First Scrip
pting
Doc Ref #: Effe ctive or Revised Date: 10/01/13
Accepted By:
B DMAS 11.01.13 App
proved by:
CSR: Person Signing Confirm
C who the person signing
s and ch
hoose from d
drop down in..
I will now
w read two sta
atements whiich will allow you to verbaally sign your aapplication over the phonee. Do
you underrstand all the questions assked and certif
ify under penaalty of perjurry that your answers were
correct annd complete to
t the best off your knowled
dge, includingg informationn about the ciitizenship or alien
a
status of each
e househoold member applied
a for?
Caller: (Yees/No)
CSR: You understand that t you are giving
g permisssion for the M
Medicaid andd FAMIS progrrams, as welll as
the Health h Insurance Marketplace,
M if necessary, to contact oth
ther persons oor organizatio
ons to obtain proof
of eligibiliity. You also understand
u th
hat there are penalties for giving false iinformation which
w could reesult
in the dennial of eligibiliity and/or pottential fraud, and that youur verbal telepphone signature has the saame
legal effecct and can bee enforced in the
t same wayy as a writtenn signature. D Do you undersstand and agrree?
Caller: (YYes/No)
[CSR if caller does not agree to either statemen
nt, inform theem we cannott complete th
he application
n]
CSR: As you
y have agreeed to both sttatements pleease give yourr name and sppell it for me..
Caller: (caller will give
e name and sp
pell it)
CSR: Than nk you Mr./MMs. ________,, we have com mpleted and ssigned your aapplication. Itt will be subm
mitted
to your Lo
ocal Department of Social Services
S for reeview. In a ffew days you will receive a letter that
confirms that
t you submmitted a phonne applicationn through Covver Virginia to
oday, and it wwill also proviide
details ab
bout your righ
hts and respon
nsibilities.
For your records,
r your Application Number
N is T##########. W
Would you likke me to repeat your
Applicatio
on Number?
CSR: I havve some addittional informa
ation that I neeed to ask annd inform youu of. Just so yyou know, thee
same infoormation or details would be
b provided non matter how w or where yoou applied.
CSR: Are you interesteed in learning more about sharing
s your personal infoormation with
h additional
Commonw wealth Agenccies? This ma ay save time iff your informaation changees because wee will be able to
coordinatte changes in your informaation with tho
ose agencies.
If No: skip consent section.
If Yes: CSR reads consent beelow:
Cover Virgin
nia Call Centeer
Script: Rig
ghts & Respo
onsibilities, C
Consent & Pla
an First Scrip
pting
Doc Ref #: Effe ctive or Revised Date: 10/01/13
Accepted By:
B DMAS 11.01.13 App
proved by:
Consent:
The Virginnia Departmeent of Social Services
S (also known as VD DSS) would likee to use somee of the perso onal
informatio on that you have
h providedd on this appliication aboutt you and youur dependentss to create your
User Profiile. VDSS is asking
a for you
ur permission to share youur User Profilee electronicallly with a limitted
number of state agenccies. Each ag gency will be told
t when youu make a chaange to the infformation in your
User Profiile. This will allow you to save time by only providinng User Profilee information n when visitinng
these ageencies. You can consent to o allow certaiin state agenccies to share this data. Ch hoosing not to o
share you
ur User Profilee will not affect the determmination of th is applicationn or eligibilityy for assistancce.
You can agree
a for VDSSS to not sharee this data, orr share this daata with yourr social securiity number, o or
share thiss data without a social secuurity number.. If you are sstill unsure att this point, I ccan continue
providing you more details about th his User Profille. {wait for a response}
If addition nal details reequested CSR: Your User Profile will onnly be created if you agreee to share it a and
you are elligible for assistance. Yourr User Profile will contain fi first name, lasst name, midd dle initial, sufffix
(Jr., Sr., ettc.), current home
h address,s, date of birth
h, Social Secuurity Number and Medicaid d identificatioon
number (if if applicable), email addresss, home pho one, driver's liicense ID, andd cell phone number.
n Howeever,
you can sh hare your Useer Profile with hout sharing your
y Social Seecurity numb er; this will no
ot affect yourr
eligibility. Your Medica aid identificattion number will
w only be shhared with VD DSS and your local departm ment
of social services.
s Becaause the User Profile is bassed on your appplication forr assistance, tthe following
agencies willw know tha at you are receiving assistaance.
The reasoons they have requested yo
our User Profiile and what tthey will be aallowed to do with your Usser
Profile aree listed.
Sharing yo our User Proffile will allow them to updaate the inform
mation in theiir computers, saving taxpa
ayer
dollars. It may save you a visit to on ne of these ag
gencies becauuse your inforrmation has been
b changedd
electroniccally.
The Department of Mo otor Vehicles (DMV) would d like a copy oof your User PProfile when itt changes. DM
MV
can changge your addreess for cars th
hat you own and/
a or driverrs license/ideentification ca
ard informatio
on
they havee on record for you. They will
w send you a card autom atically throuugh the mail to t complete this
update.
The Virgin
nia Informatio on Technolog gies Agency (VVITA) operatees an electronic system knoown as Enterpprise
Data Man nagement (ED DM). EDM con ntains data th
hat you have already proviided to DMV forf your driveers
license or identification
n card. If you give permissiion to share yyour User Prof
ofile, EDM will match the D
DMV
Cover Virgin
nia Call Centeer
Script: Rig
ghts & Respo
onsibilities, C
Consent & Pla
an First Scrip
pting
Doc Ref #: Effe ctive or Revised Date: 10/01/13
Accepted By:
B DMAS 11.01.13 App
proved by:
data and your User Pro ofile, and share this inform
mation with yoour local depaartment of so
ocial services and
DMV. Iff the data doees not match,, DMV or yourr local departtment of sociaal services ma ay contact yoou to
confirm thhe informatio on. Email addrress, home ph hone number, r, cell phone nnumber, and yyour Medicaiid
identificattion number may
m be review wed by a locaal departmentt of social serrvices worker inside EDM to
t
identify poossible dupliccate User Proffiles.
If you cho
oose not to share your Userr Profile: Yo
our informatioon will remainn only with th he Departmen nt of
Social Serrvices. Choosin
ng not to sha
are your User Profile will noot affect yourr eligibility forr assistance.
Social Seccurity Numberr: Including your
y Social Seecurity Numbber (SSN) in yoour User Profiile is your cho
oice.
The SSN iss used to mattch your User Profile with DMV
D data in EDM more efffectively. Youur SSN is keptt
confidential.
Dependen nts: This requuest is for you
ur own User Profile
P and forr the User Proofile of any peerson who is yyour
legal depeendent, includ
ding your chilldren under age
a 18, any peerson for whoom you serve as legal guarrdian,
or any oth
her person forr whom you have
h the auth
hority to agre e to share infformation.
To stop sh
haring of yourr User Profile: You can sto op sharing youur User Profille at any timee by going to
www.com mmonhelp.virg ginia.gov and d changing yoour decision too share. You ccan also channge your decission
to share your
y User Proffile by visiting
g your local department
d off social servicces.
Your permmission to shaare your User Profile will reemain active ffor one (1) yeear from the d
date you apprrove,
unless youu change your decision to share
s soonerr. Your agreemment for any m minor child w
who turns 18 will
w
be stoppeed on the datee of the childs 18th birthd
day. That indivvidual will theen be asked to agree to sh
hare
his or her information. You will be asked
a to sharee your inform
mation every ti time you make a change to o the
informatioon that is useed in your Useer Profile.
[CSR: Input answer as:
No, if th
hey do not aggree to the consent or
Yes, allo
owed to share e with SSN orr
Yes, allo
ow to share but
b without SSSN]
CSR: Are you
y a registerred to vote att your currentt address?
[If Yes: Ch
hoose No, client
c does no
ot need info on
o voter registtration and go to next queestion]
If No: CSR
R: Would you u like informa
ation on how to register to vote?
If No: Choosse No that client
c does no ot need info oon voter regisstration
If Yes: Choose Yes so cllient will receeive info on vo
oter registrattion `
Cover Virgin
nia Call Centeer
Script: Rig
ghts & Respo
onsibilities, C
Consent & Pla
an First Scrip
pting
Doc Ref #: Effe ctive or Revised Date: 10/01/13
Accepted By:
B DMAS 11.01.13 App
proved by:
CSR: Onee other note, your
y applicatiion for Mediccaid and FAM MIS will be dettermined by thhe local
deepartment off social servicees. If any perrson betweenn the ages of 119 through 84 4 who did nott
qu
ualify for Meddicaid or FAMMIS benefits, will
w be evaluaated for a bennefit called Plaan First.
Plan First is a Medicaidd Program tha at provides fa amily plannin g services, orr pregnancy p
prevention serrvices
nly, to both males
on m and fem
males. You may m choose if you do not w want an individdual evaluateed for
th
he Plan First program.
p You can also choose to opt oout and not haave a Plan Firrst evaluationn
do
one on the en ntire applicatiion. This will have
h no effecct on the deteermination for Medicaid orr
FA
AMIS coverag ge, simply let me know at thist time.
[CSR: If applicant choo oses to opt ouut, enter a VaaCMS note su ch as Appliccant has choseen to opt outt and
not be evaluatted for Plan First program.]
CSR: Than nk you for alll of this inform
mation. If theere is any addditional inform
mation requirred, you will b
be
contactedd by your loca
al departmentt of social services office. Once a decission is made, you y will be
notified by mail.
Is there an
nything else I can assist yo
ou with todayy? Unless you have other qquestions Mr.//Ms. _________, I
want to thhank you for calling Cover Virginia. Myy name is ______________________. Havve a good dayy!
