Citizenship/Identity Documents

Acceptable Citizenship/Identity Documents

To establish U.S. citizenship, an acceptable document must show a U.S. place of birth or that the person is a U.S. citizen or national.

Acceptable verification for citizenship and identity are grouped as follows:

Tier one (or Level 1) evidence is the most reliable and establishes both citizenship and identity.
Tiers two through four are less reliable groups of documentation of citizenship only. Evidence of identity must also be provided.
Tier five includes identity documents.

Refer to Identity Proofing and Verification Examples.

Note: Expired documents are acceptable proof of citizenship/identity.

If a client originally provided a less reliable document (Tier 3 or 4) but later provides a document of higher reliability (Tier 1 or 2), the case information must be updated to reflect the higher level of verification

DRA Citizenship Document Tiers 1‐4:

Hierarchy of Reliability of Citizenship Documents

Evidence of Highest Reliability<<<<<<<<<<<<<<>>>>>>>>>>>>>>Evidence of Lowest Reliability

Primary Documents (Tier 1)

Establishes both Citizenship & Identity

Secondary Documents (Tier 2)

Must be Provided with Identity Document

Third Level Documents (Tier 3)

Must be provided with Identity Document

Fourth Level Documents (Tier 4)

Must be Provided with Identity Document

U.S. passport issued without limitation
Certificate of Naturalization (DHS Forms N-550 or N-570)
Certificate of Citizenship (DHS Form N-560 or N-561)

U.S. Public Birth Record issued before age 5 (1)
Certification of Report of Birth (DS-1350)
Certification of Birth issued by the Department of State (Form FS-545 or DS-1350)
Report of Birth Abroad of a U.S. Citizen (FS-240)
U.S. Citizen ID Card (Form I-197 or I-179)
American Indian Card (I-872)
Northern Mariana Identification Card (I-873)
Final Adoption Decree (2)
Evidence of Civil Service employment by U.S. Government showing employment before 6/1/76
U.S. Military Record (2)

Extract of a Hospital Record on Hospital Letterhead Established at the time of Birth (2,3)
Life or health or other insurance record (2,3)

Federal or State Census Record showing U.S. Citizenship or a U.S. place of birth (Generally for individuals born 1900-1950) (4)
Seneca Indian tribal census record (2,3)
Bureau of Indian Affairs tribal census record of the Navaho Indians (2,3)
U.S. State Vital Statistics official notification of birth registration (2,3)
Amended U.S. public birth record amended more than 5 years after the person’s birth (2,3)
Statement signed by the physician or midwife who was in attendance at the time of birth (2,3)
Institutional admission papers from a nursing facility, skilled care facility or other institution
Medical (clinic, doctor or hospital) record (excludes immunization records)(2,3)
Written Affidavit (5)

Must show birth in: one of the 50 U.S. States; District of Columbia, America Samoa, Swain’s Island; Puerto Rico (DOB on or after 1/13/41); Virgin Islands of the U.S. (DOB on or after 1/17/17), Northern Mariana Islands (DOB after 11/4/86, NMI local time); or, Guam (DOB on or after 4/10/1899).
Must show U.S. Place of Birth
Must have been created at least 5 years before the Medi-Cal application, unless applicant is a child under the age of 5
Must show applicant’s age
Affidavits should only be used in rare circumstances. An Affidavit by at least two individuals of whom one is not related to the applicant/beneficiary and who have personal knowledge of the event(s) establishing the applicant’s/beneficiary’s claim of citizenship. The person(s) making the affidavit must be able to prove his/her own citizenship and identity for the affidavit to be accepted. A second affidavit from the applicant/benefi- ciary or other knowledgeable individual explaining why documentary evidence does not exist or cannot be readily provided must also be obtained.

DRA Identity Document Tier 5

Acceptable Verification of Identity for Citizens and Nationals who do not Provide a Tier 1 Citizenship Document (Tier 5)
Certificate of Degree of Indian Blood, or other U.S. American Indian/Alaska Native Tribal document. (Acceptable if the document carries a photograph of the applicant or beneficiary, or has other personal identifying information relating to the individual.)
Driver’s license issued by State or Territory either with a photograph of the individual or other identifying information of the individual such as name, age, sex, race, height, weight or eye color.
School identification card with a photograph of the individual
U.S. military identification card or draft record
Identification card issued by the Federal, State, or local government with the same identifying information included on driver’s licenses
U.S. military dependent’s identification card
Native American Tribal document
U.S. Coast Guard Merchant Mariner card
For children under 16, school records may include nursery or day-care records
An affidavit to establish identity of children under 18 is only acceptable if signed under penalty of perjury by a parent or guardian stating the date an place of birth of the child, and cannot be used if an affidavit for citizenship was provided (The affidavit of identity is permanently valid)
A U.S. Passport, current or expired, even if issued with limitation.

NOTE: Expired identity documents are acceptable for proof of identity.

Original Documents

All documents provided as verification of citizenship and identity must either be originals or copies certified by the issuing agency. Uncertified copies or notarized copies do not meet the DRA requirements. Clients may provide original documents in person, by mail or by an authorized representative.

Use of Affidavits for Citizenship

Affidavits may be used in situations where no other acceptable proof of citizenship is available. Affidavits may not be used for both citizenship and identity. In order for an affidavit to be acceptable to establish citizenship, the following requirements must be met:

No other evidence of citizenship can be obtained by the applicant/client.
The affidavit(s) must be signed under penalty of perjury by at least two individuals who have personal knowledge of the event(s) establishing the applicant’s or client’s claim of citizenship
At least one of the individuals providing an affidavit must not be related to the applicant/client.
The applicant/client and the individuals completing the affidavit must provide proof of their own citizenship and identity. Copies of the witnesses original documents and forms must be scanned into IDM.
If the affidavits do not explain why other evidence is unavailable, an additional affidavit (which provides the reason for unavailability), signed by the applicant or client or other knowledgeable individual, must be obtained.

The following forms may be used as affidavits:

“Affidavit of Reasonable Effort to Get Proof of Citizenship” (DHCS 0003)
“Affidavit of Identity for U.S. Citizen Children Under 18” (DHCS 0009)
“Affidavit of Citizenship” (GEN 853).

Note: Most children born in California should meet the documentation requirements based on a birth record match and a signature on the application form.

Use of Affidavits for Identity

An affidavit to establish the identity of children under 18 is only acceptable if it is signed under penalty of perjury by a parent or guardian stating the date and place of birth of the child. An affidavit for identity cannot be used if an affidavit for citizenship was provided. If the child is 18 or older, an affidavit is not acceptable to document the identity of the child.

The “Affidavit of Identity for U.S. Citizen Children Under 18” (DHCS 0009) may be used as verification of identity for children under age 18.

Original Document Certification Forms

The “Proof of Citizenship or Identity Received” (DHCS 0005) is completed for each individual and signed by clerical staff to certify that a document submitted for verification of citizenship or identity is an “original” document or certified copy from the issuing agency.

A copy of the DHCS 0005 receipt must be given to the client as a receipt that an original or certified copy was provided.
If an original document is received by mail, staff must immediately make a copy and date stamp the COPY. The DHCS 0005 must be completed. The original document along with a copy of the DHCS 0005 must be returned to the client via CERTIFIED mail with a return receipt. The copy of the documents and the DHCS 0005 are given to the EW and also scanned into IDM
The original signed DHCS 0005 must be scanned into IDM - Permanent Verifications and given to the EW along with a copy of the document(s) submitted.
The EW will determine if the document submitted is acceptable or not acceptable and notify the client of the determination.
The “Proof of Acceptable Citizenship or Identity Documentation” (DHCS 0011) must be completed by the EW to notify the client that they have submitted an acceptable citizenship and/or identity document.
The DHCS 0011 must be given to the client in person or mailed to the client after the document(s) are reviewed by the EW.
If the document submitted is not acceptable, the EW will inform the client that another form of verification is necessary.
A copy of the DHCS 0011 must be scanned into IDM under Permanent Verifications.

Note: If a client provides documents directly to the EW either in person or by mail, ONLY the DHCS 0011 needs to be completed and given/mailed to the client.

Document Certification by CAAs

Employees of Disproportionate Share Hospitals (DSH) and Federally Qualified Health Centers (FQHC) are qualified to view and certify original documents and complete the DHCS 0005. This includes Certified Application Assistors (CAAs) employed by Santa Clara Valley Health and Hospital Systems (HHS). A DHCS 0005 signed by a CAA employed by HHS is valid and is acceptable proof that the original document was viewed.

Reasonable Opportunity Period

All applicants and clients must be given a “reasonable opportunity” period to provide citizenship and identity documents. This period is defined as the time needed for the client to obtain acceptable verification of citizenship/identity based on:

the individual’s circumstances,
ability to obtain the verification, and
a good faith effort

EWs must initially allow for 90 days for the individual to provide the necessary documentation, Jounral that documentation is pending, and follow up at the end of th 90 day period. If the individual has not provided documentation at the end of the 90 day period, the EW must explore what actions the individual has taken to obtain the documentation. The EW must extend the ROP date if the individual is making a good faith effort to obtain the proper documentation. The EW must record all actions taken by the individual and the EW to obtain the appropriate documentation.

The “Proof of Citizenship or Identity Needed for MC Applicants and Clients Who Are U.S. Citizens or Nationals” (DHCS 0006) is used to request verification of citizenship and/or identity from the client. The DHCS 0001 for applicants or the DHCS 0002 for clients or the “Medi-Cal Rules Have Changed” (SCD 265) in the appropriate language must also be included, as the DHCS 0006 does not include a list of acceptable citizenship/identity documents.

Clients with Mismatching SSN Results

Applicants and clients who fail the SSN data match must be sent the Information Notice “Unable to Verify U.S. Citizenship/Identity Through the Social Security Administration” (MC 239 DRA-6). They have 90 days from the date they receive the notice to resolve the mismatch. The 90-day period starts seven (7) calendar days after the date of the Information Notice.

If acceptable proof of citizenship/identity is not provided or the inconsistency is not resolved with SSA, the applicant or client’s MC must be reduced from full-scope MC to restricted-scope MC benefits with a timely ten-day NOA.

Acceptable verifications include:

Social Security Card, or
An Award letter, Medicare card or a check from SSA showing applicant's name and SSN, with the letters A, HA, J, T, or M following SSN, or
MC 194 (requires follow-up in 60 days)
A parent may request an SSN at the time that the hospital obtains information for birth registration. The SSA-285-OP3 “Message from Social Security” can be used as evidence of SSN application when signed by a hospital official.

Resolving Mismatches

If the non-exempt individual’s SSN data match is unsuccessful make a reasonable effort to address the mismatch by checking for correctable errors (i.e. confirm SSN with client, is the date of birth correct, is the gender correct, is the name correct, etc.) and update CalSAWS with the correct information.

If mismatch cannot be resolved as described above, request the client to provide acceptable citizenship/identity documentation OR refer the client via form MC 194 to SSA to have the inconsistency resolved.

Documents Received After Restricted-scope Benefits are Granted

For applicants or clients whose benefits are reduced from full-scope MC to restricted-scope MC for failure to provide evidence of citizenship/identity, their full-scope MC benefits may be restored back to the month restricted-scope MC benefits began, if they provide required verification within one year of the date of application or redetermination and any applicable retroactive months if good cause exists.

If documents are provided more than one year after the application or redetermination date, or if good cause does not exist, grant full-scope MC eligibility effective the first of the month in which the verification is provided.

Adding a Person to an Existing Case

When adding a person who is not currently receiving MC to an existing case, that person is considered a new applicant and full-scope MC benefits must be granted during the ROP while the individual obtains verification of citizenship and identity.

When adding a person who was already eligible for MC, he/she is considered a client and continues to receive ongoing MC during their ROP, if all other eligibility factors are met.

Good Faith Effort

An applicant/client is making a good faith effort if he/she dis trying to provide acceptable documents to meet the citizenship/identity requirements. If a client is making a good faith effort to provide documents, the allowable time for completing the necessary contacts and follow up to assist them must be extended. The EW must thoroughly explain good faith effort to the client so the client is aware that they will be granted additional time if necessary.

Examples of good faith effort include, but are not limited to:

Providing a copy of a request for a document sent to the appropriate agency such as, a photocopy of a letter, a copy of an e-mail or a receipt for the requested document from the agency who will issue the document.
Providing copies of documents along with verification that an original or certified copy of an acceptable document has been ordered (i.e. receipt).
- Note: If the client was born in California, initiate an AP 19 transaction for an electronic birth record match before requiring the client to provide an original document.
Written or verbal statements of effort to obtain citizenship documents, such as an “Affidavit of Reasonable Efforts to Get Proof of Citizenship” (DHCS 0003).
A written or verbal update of progress made in obtaining verification of citizenship or identity.
A written or verbal explanation of attempts to locate two individuals who could attest to the applicant’s/client’s citizenship.

EWs must document all descriptions of a client’s good faith efforts, including dates and the expected time the client will need to obtain documents, and the reason for the determination that a client is no longer making a good faith effort in Journal Entry.

Providing Client Assistance

Staff must assist applicants/clients in obtaining verification of citizenship and identity whenever necessary. This includes situations when a client is incapable of taking the steps necessary to obtain the required documents due to incapacity or disability or the client is unable to provide documents for any reason.

Examples of providing assistance include, but are not limited to:

Reviewing and explaining acceptable verification of citizenship/identity
Explaining how to provide proof of good faith effort to obtain documents
Determining the possible acceptable documents that may be available to the client based on his or her individual circumstances
Providing any resources available such as the name, address and telephone number of the vital statistics agency where the client can obtain the documents.

Requesting Birth Certificates

When a client is unable to provide an acceptable citizenship document and was born outside of California, or was born in California but an electronic birth record match is unsuccessful, EWs are to complete the “Clerical Check Sheet” (SCD 109) to request a certified copy of the client’s Birth Certificate.

Requesting Identity Documents

When a client is unable to provide acceptable identity document, EWs are to complete and issue the “Verification for Reduced Fee Identification Card” (DL 937) to the client to obtain a California ID from the Department of Motor Vehicles at a reduced cost. Allow the client 10 days to provide the ID.

Note: The DL 937 and DL933 are shelf stock forms from the DMV, copies will not be accepted. The Office Management Coordinator (OMC) for each office maintains the supply of these forms.

There are two versions of these forms:

DL 937 (Blue)- Reduced Fee
DL 933 (Gold)- No Fee (only for homeless clients)

Assistance Examples

The following are guidelines on some of the ways staff can provide assistance:

Example 1: Client born outside of California (Tier 3)Example 1: Client born outside of California (Tier 3)A mother is applying for herself and her child, both U.S. citizens born in another state. Only the child has an original birth certificate. The mother has a California Drivers License and she listed a life insurance policy on her MC application. The EW should determine if the life insurance policy was issued over five years ago and indicates a U.S. place of birth. If yes, the life insurance policy is acceptable proof of her citizenship if she does not have more reliable proof. The EW will need to view and copy the original life insurance policy.

Example 2: Lost Naturalization Papers in a Fire (Tier 2)Example 2: Lost Naturalization Papers in a Fire (Tier 2)A family applies for MC and both parents indicate they are naturalized U.S.citizens but have lost their naturalization certificate/papers. Prior MC case records show alien registration numbers/documents for both parents. Initiate SAVE, if unsuccessful, the EW will refer them to the closest U.S. Citizenship and Immigration Services office to obtain copies of their naturalization documents.

Example 3: Deemed Eligible Infants (Exempt)Example 3: Deemed Eligible Infants (Exempt)A mother applies for herself and her one child. Both were born in California but the mother does not have original birth certificates. The child was born in 2004 while on aid and was deemed eligible for MC at that time. The EW should initiate a request for a MEDS birth record match for the mother by obtaining information on the DHCS 0004. No evidence of citizenship or identity is required for the child since the child was previously deemed eligible for MC.

Example 4: No Record of Birth (Tier 4)Example 4: No Record of Birth (Tier 4)A granddaughter is applying for her aged grandmother with Alzheimer’s, who was born in Kansas at home. The granddaughter states that there is no record of birth. After determining there is no other proof of citizenship available, the EW must explain what is required to provide an affidavit as verification of citizenship. Requirements for the affidavit must be met in order to meet the citizenship verification requirement.

Example 5: Some Family Members Do Not Have Verification (Tier 4)Example 5: Some Family Members Do Not Have Verification (Tier 4)A mother applies for MC for herself, her spouse and their three children. All family members were born in the U.S. The family has never been on aid prior to this application. The mother provides original birth certificates for herself and her three children. She does not have an original or certified birth certificate for her husband. Eligibility for all family members must be granted as soon as possible without waiting for the husband’s verification, if all other requirements are met. The father was born in Texas. The EW provides the client with the name, address and telephone number of the Vital Statistics agency in Texas. In addition, the EW completes the SC 109 to request a certified birth certificate from the state of Texas. Note: EWs can find the Vital Statistics office for each state at http://www.vitalrec.com

Example 6: Disabled IndividualExample 6: Disabled IndividualA disabled adult man applies for MC at a mental health facility. The applicant states he is a U.S. born citizen but does not have any citizenship or identity verification because he is homeless. The applicant is not currently capable of providing proof of his citizenship. If the client was born in CA, the EW must explore the option of a birth record match by asking for the information needed on the DHCS 0004. If the data match is unsuccessful, the EW must complete the SCD 109 to request a certified birth certificate and the DL 937 for the client to obtain a California ID at reduced cost, or DL 933 for homeless clients for no cost.

Example 7: Client Has No Money to Obtain VerificationExample 7: Client Has No Money to Obtain VerificationA hospitalized applicant applies for MC with the assistance of a patient advocate. The applicant is a mother with a 19-year-old son living in the home who attends a continuation high school. The applicant states she and her son are U.S. born citizens but she has no birth certificates. The EW explains acceptable documents including affidavits. The applicant states they have no funds to secure the original document and is unable to find anyone to complete the affidavit. The EW must complete SC 109’s to request certified birth certificates for both.

Example 8: Pregnant Woman Example 8: Pregnant Woman An applicant who is two months pregnant applies for MC. She declares U.S. citizenship, but citizenship cannot be e-verified immediately. The client will be granted the pregnancy aid code she is eligible for (depending on income) during the 90-day Reasonable Opportunity Period (ROP). The EW initiates a MEDS AP 19 birth record match which is unsuccessful. The EW explains acceptable documents including affidavits. If the client is unable to provide verification, the EW completes the SCD 109 to request a certified birth certificate.

Exempt Individuals

Individuals in the following groups are exempt from citizenship and identity requirements:

Current Supplemental Security Income (SSI) clients
- Note: When a person loses SSI (Craig v. Bontá client) and eligibility is determined forMC-only, verification of citizenship/identity is required. Refer to Craig v Bontá - Loss of SSI/SSP.
Social Security Disability Insurance (SSDI – Title II) clients
Social Security Retirement and Survivors Insurance (RSDI – Title II) clients who receive those benefits based on their own disability
Current Medicare clients
Minor Consent applicants and clients
MC Dialysis Only Program (Aid Code 71) applicants/clients
Total Parenteral Nutrition (aid Code 73) applicants/clients
Medically Indigent Long Term Care (Aid Code 53) applicants/clients
Children receiving foster care or adoption assistance, including Kinship Guardianship Assistance Payment (Kin-GAP) recipients
Former Foster Youth in Aid Code 4M
Deemed eligible infants who are born in the U.S. and are citizens (including children born to non-citizen mothers whose delivery was covered by MC)
Infants eligible under the Abandoned Baby Program who are born in the U.S. and have no documentation.

Presumptive Eligibility (PE) Programs

Individuals receiving MC benefits in the following programs are exempt from the citizenship/identity requirements when PE is established:

Presumptive Eligibility for Pregnant Women
Presumptive MC Eligibility under the Breast and Cervical Cancer Treatment Program (BCCTP)
Child Health and Disability Prevention (CHDP) Gateway program
MC Accelerated Enrollment at the Single Point of Entry National School Lunch Program.

Note: Clients must be placed in the appropriate aid code for ongoing MC eligibility as soon as they are found to be otherwise eligible, if they are making a good faith effort to obtain DRA citizenship/identity documents.