Get Dhs1179a

The Dhs1179a, or change of circumstance report form, is essential for reporting significant changes to your household. This guide provides clear instructions on how to accurately fill out the form online.

Follow the steps to fill out the Dhs1179a form online.

1. Click ‘Get Form’ button to obtain the form and open it in the digital editor.
2. Enter the primary individual name in the designated field. Include the last name, first name, and middle initial.
3. Provide the date of birth in the specified format (mm/dd/yyyy).
4. Enter the Client ID or Social Security Number (SSN) as required.
5. Fill in the current address, including street, city, state, and zip code. Also, provide a current phone number.
6. Indicate if you are completing the form on behalf of the Medicaid beneficiary by checking the appropriate box for 'Authorized Representative' or 'Legal Guardian, POA or Conservator'.
7. In Section 1, specify if you are terminating the medical assistance case by entering the effective date and reason.
8. Complete Section 2 if you are requesting a name change. Enter the old name and new name and attach the necessary legal documentation.
9. Update any changes in address or telephone numbers in Section 3. Indicate if the changes apply to all household members.
10. If applicable, fill out Section 4 regarding pregnancy changes, including the pregnant individual's name and due date.
11. In Section 5, report or change third-party liability coverage details, including insurance information and effective dates.
12. Use Section 6 to report changes in household members, specifying if you are adding or deleting members and providing their details.
13. Complete Section 7 to report changes in income, specifying the type of income and effective dates.
14. If there are other changes to report, use Section 8 to indicate them.
15. Make sure to add your signature and date at the bottom of the form to certify the information provided.
16. After completing the form, you can save changes, download, print, or share the form as needed.

Complete your documents online for convenience and accuracy.