A Maryland resident diagnosed with end-stage renal disease may apply for certification with the Program. An applicant, or the applicant's representative, shall complete a written application on the form designated by the Program. Application Supporting Documents. The Program may require the following as part of the application form or in addition to the application form: Copies of the previous year's federal income tax return of the applicant and each individual in the applicant's family; Current statements of liquid assets owned by the applicant and each individual in the applicant's family; The amount of the current Social Security benefits and all retirement or pension benefits, or both, of the applicant and each individual in the applicant's family; Documentation of the applicant’s identity as well as citizenship or nationality, to the Department’s satisfaction, based on federal requirements; Verification of the applicant's status as a resident of Maryland; Verification of the applicant’s Medicare status; Verification concerning the applicant's enrollment in any health insurance benefit plan; Physician's certification that the applicant has ESRD; Physician's certification that the applicant has begun a regular course of maintenance renal dialysis in a certified facility or received a renal transplant, or both; A signed statement authorizing the Program to verify, from any source including banks, insurance companies, and public or private agencies providing monetary benefits, information submitted to the Program by the applicant; and Other information the Program determines is needed to establish whether the applicant is eligible to be a recipient. Refusal to sign an authorization that may be required under §C(1)(j) of this regulation is considered failure to provide sufficient information, and the applicant will be determined ineligible without prejudice in accordance with §F of this regulation. In reference to §C(1)(a) of this regulation, the Program may accept the previous year's tax return through April 15 of the year in which an application for certification is filed. After April 15, the Program requires the new tax return or proof of extension granted for filing a return. Signature Requirements. For the purpose of establishing eligibility, the applicant or the applicant's representative, as appropriate, shall complete and sign the application form. A physician shall sign the certification that the applicant has ESRD and has begun a regular course of maintenance renal dialysis, or has received a renal transplant, or both. The applicant or the applicant's representative shall forward the completed application form and supporting documents to the address designated on the form. An applicant shall provide all required information within 90 days from the date the information is originally requested by the Program or the applicant shall be determined ineligible without prejudice and may reapply. The applicant, or the applicant's representative, may voluntarily withdraw an application at any time without prejudice. If the Program determines that an applicant is not eligible for Program enrollment, the Program shall notify the applicant or the applicant's representative, as appropriate, in writing within 45 days of receipt of a completed application and include the following in the notice: The basis for the determination of ineligibility; An explanation of the right to request a hearing; and A statement that the applicant is permitted to submit a new application for Program enrollment at any time. If the Program determines that an applicant is eligible for Program enrollment, the Program shall: Establish a certification period in accordance with Regulation .03C of this chapter; Notify the applicant or the applicant's representative, as appropriate, in writing within 45 days of receipt of a completed application; Issue a Kidney Disease Program recipient identification card and instructions for using the card; and Notify the applicant or the applicant's representative, as appropriate, about any Program participation fee due in accordance with Regulation .04 of this chapter.