Get Dhs-4106c-eng (health Plan Enrollment Form For People 65 Or ... 2020-2025

Filling out the DHS-4106C-ENG health plan enrollment form is essential for people 65 years old or older seeking health coverage. This guide provides clear, step-by-step instructions to help you complete the form accurately and efficiently online.

Follow the steps to successfully complete the enrollment form.

1. Click ‘Get Form’ button to obtain the form and open it for completion.
2. Begin by filling out the enrollee information section. Ensure to correct any inaccuracies in information such as your last name, first name, middle initial, date of birth, and gender. Additionally, provide your permanent street address, county, home phone number, city, state, and ZIP code.
3. If your mailing address differs from your permanent address, complete the mailing address section. This includes city, state, and ZIP code.
4. Indicate your case number and PMI. Next, answer whether you live in a long-term care facility, select 'Yes' or 'No' in the provided box.
5. Verify your Medicare information. If correct, select 'Yes'; if incorrect, select 'No' and provide the correct details in the space provided, including your Medicare number and start dates for Hospital (Part A) and Medical (Part B).
6. Indicate whether you require an interpreter by selecting 'Yes' or 'No'. If 'Yes', check the relevant language box from the options provided.
7. Answer the important eligibility questions regarding end-stage renal disease and current health insurance coverage, ensuring to provide the insurance company's name, group number, policyholder's name, and policy or ID numbers for any additional coverage.
8. Choose a health plan by checking one of the provided boxes. If you do not select a plan, the plan marked with a star (★) will be your default health plan.
9. If applicable, complete the section for the primary care clinic or care system you are selecting, including the Primary Care Clinic (PCC) number.
10. Review the agreement section carefully. By signing, you acknowledge your understanding of the terms. Sign and date the form, ensuring to include the name and relationship of any authorized representative if applicable.
11. After completing the form, save your changes, and choose to download, print, or share the form as needed.

Complete your DHS-4106C-ENG health plan enrollment form online today for seamless health coverage.