Medicare Current Beneficiary Survey (MCBS):(CMS Number CMS-P-0015A)

Created 1/1/10

HI3

Sample Medicaid Card - Tennessee (TN)

[Card image varies by Medicaid plan name.]

Created 1/1/10

HI3
Sample Medicaid Card - Texas (TX)

Created 1/1/10

HI3
Sample Medicaid Card - Texas (TX)
(continued)

Created 1/1/10

HI3
Sample Medicaid Card - Utah (UT)

Created 1/1/10

HI3
Sample Medicaid Card - Vermont (VT)

Created 1/1/10

HI3
Sample Medicaid Card - Virginia (VA)

COMMONWEALTH OF VIRGINIA
DEPARTMENT OF MEDICAL ASSISTANCE SERVICES

002286

999999999999
V I RG I N I A J. R E C I P I E N T
DOB: 05/09/1964

22

F

CARD# 00001

Created 1/1/10

HI3
Sample Medicaid Card - Washington (WA)

Created 1/1/10

HI3
Sample Medicaid Card - West Virginia (WV)

Created 1/1/10

HI3
Sample Medicaid Card - Wisconsin (WI)

Created 1/1/10

Sample Medicaid Card - Wyoming (WY)