Get Dch 0078 Form

The DCH 0078 Form is an important document used to request changes in other insurance status for Medicaid beneficiaries. This guide provides clear and straightforward steps to complete the form online, ensuring a smooth submission process.

Follow the steps to complete the DCH 0078 Form online

1. Click the ‘Get Form’ button to access the DCH 0078 Form and open it in your preferred document editor.
2. In Section 1, provide the required details about the Medicaid provider or caseworker, including requestor name, date, phone number, and case number if available. Ensure to complete all mandatory fields marked with an asterisk (*).
3. Proceed to Section 2, where you will list the beneficiaries or clients whose insurance status needs to be changed. Fill in their names, dates of birth, and mihealth IDs correctly for accurate processing.
4. In Section 3, provide policyholder information, including the policyholder's full name, date of birth, social security number, employer details, and type of coverage. Use an 'X' to indicate the type of insurance coverage applicable.
5. Next, state the reason for the change in Section 4. Choose from the options provided, such as divorce or employment termination, and specify relevant dates. If applicable, include additional documentation to support your request.
6. Review all the information entered to ensure accuracy. Once confirmed, you can proceed to save your changes, download, or print the completed DCH 0078 Form for submission.

Complete your documents online today for a more efficient process.