Get Ldss 4411 Form

Filling out the Ldss 4411 Form online is an essential step for individuals seeking Medicaid, Family Health Plus, or Child Health Plus A renewal. This guide offers a clear and structured process to help users accurately complete each section of the form, ensuring a smooth renewal experience.

Follow the steps to fill out the Ldss 4411 Form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your personal information in the designated fields. Ensure that all entries are correct and up-to-date, especially your name, date of birth, and program code.
3. Review the pre-printed social security number section. If your SSN is on file, it will indicate 'On-File'. If not, write your SSN into the provided space.
4. Answer sections regarding your household size. Identify any additional household members who are not currently receiving assistance but will be counted.
5. If applicable, report if anyone in your household is pregnant, providing the expected due date and any necessary medical verification.
6. Indicate any changes to your address or housing situation. Document these changes clearly for accurate processing.
7. Complete the income section, where you'll need to list current earned and unearned income amounts and submit corresponding documentation.
8. Provide details about any changes in health insurance. If you've obtained new coverage, attach a copy of the insurance card.
9. Ensure to fill out the resources section as required, detailing any changes in your assets or resources since your last renewal.
10. Review the Terms, Rights, and Responsibilities section carefully, sign where indicated, and make sure all required documentation is included.
11. Once all information is complete and accurate, submit the form by returning it to your local social services district. Save a copy of the completed form for your records.

Start filling out your Ldss 4411 Form online today to ensure your continued health coverage.