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Get Form 284 Fillable
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How to fill out the Form 284 Fillable online
Filling out Form 284, which is used to certify the Medicaid coverage for newborns of eligible mothers, can be a straightforward process. This guide provides step-by-step instructions to ensure that you accurately complete the form online.
Follow the steps to fill out the Form 284 Fillable online.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- In the block at the top left, enter the name and address of the mother. Ensure that all details are accurate and complete.
- In the top right section labeled Agency/Hospital, enter the name of the hospital or agency, followed by the contact person's name, phone number, and fax number if applicable.
- In response to the first question, enter the name of the child in the designated field.
- Indicate the sex of the child by marking an ‘X’ in the appropriate box next to 'Male' or 'Female'.
- Enter the child’s date of birth in the format requested in the designated field.
- If the child has a Social Security number, enter it. If not available, note that application for one should be made through Social Security, and notify Medicaid once received.
- Indicate whether the child will live in the home with the mother by marking ‘Yes’ or ‘No’.
- Indicate if the child requires additional days in the hospital by marking ‘Yes’ or ‘No’.
- The mother should sign the form in the designated area to validate the information provided.
- Enter the mother’s Social Security number in the appropriate field.
- Provide the mother’s daytime telephone number, including the area code.
- Indicate whether the mother receives SSI by marking ‘Yes’ or ‘No’.
- Once all fields are filled accurately, save the changes, and download the completed form. You may also choose to print or share it as needed.
Complete your documents online to ensure prompt processing of the Medicaid coverage for your newborn.
To send a form via fax, you should first print your completed Form 284 Fillable. Make sure it is legible and that all information is accurate. Load the form into the fax machine, enter the recipient's fax number, and send. Always keep a confirmation page for your records.
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