Get Doh 4392

The Doh 4392 form, also known as the Request for Additional Information form, is essential for maintaining your EPIC coverage and possibly obtaining federal benefits such as Extra Help for Medicare Part D. This guide will provide clear, step-by-step instructions to help you complete the form accurately.

Follow the steps to successfully fill out the Doh 4392 form.

1. Click the ‘Get Form’ button to obtain the Doh 4392 form and open it in your chosen editor.
2. Review the introductory section of the form. This section explains the purpose of the form and the importance of providing accurate information to maintain your EPIC coverage.
3. Indicate your marital status by checking either 'Single' or 'Married.' If married, please enter your spouse's date of birth if they are not enrolled in EPIC.
4. Fill in both your and your spouse's last names, first names, middle initials, and EPIC ID numbers. Ensure all names are spelled correctly.
5. Complete the mailing address section, including box or apartment number, city, state, and zip code.
6. Enter both your and your spouse's Social Security numbers in the designated fields.
7. In the income section, report the current monthly income for both you and your spouse before deductions by completing each relevant line. If there is no income to report for a particular line, enter $0.
8. For the assets section, provide the current balance for bank accounts and other investments. Exclude items such as your home or personal possessions and enter $0 if applicable.
9. If applicable, answer questions related to expected earnings, stopping work, or expenses for enabling your spouse to work, following the same guidelines for reporting income.
10. Carefully read the certification statement at the end of the form, then sign and date the document. If assistance was provided, include the name and contact information of the individual who helped you.
11. At the final step, review your completed form for accuracy. Once verified, save changes, and either print or share the form as necessary.

Don't delay; complete the Doh 4392 form online to ensure your EPIC coverage continues without interruption.