Get Decline Medicaid Coverage Form - Dc Health Link

This guide provides clear, step-by-step instructions on how to fill out the Decline Medicaid Coverage Form for DC Health Link online. It is important to understand each component of the form to ensure accurate completion and submission.

Follow the steps to successfully complete the form.

1. Press the ‘Get Form’ button to obtain the Decline Medicaid Coverage Form and open it for editing.
2. Fill in your name, DC Medicaid number or Social Security Number (SSN), address, city, state, zip code, telephone number, and email address in the designated fields.
3. Indicate the individual for whom you are declining Medicaid health coverage by selecting the appropriate option: yourself, spouse, or dependent(s). Ensure to provide their name(s) and corresponding DC Medicaid number or SSN.
4. Read the acknowledgment section carefully. By signing the form, you confirm that you understand your responsibilities regarding minimum essential health coverage and any potential tax penalties.
5. If you want to waive your 15-day advanced notice, check the relevant box provided. This will mean your coverage will end on the last day of the month when your request is received.
6. Sign the form in the designated area, print your name, and include the date to validate the information you provided.
7. After completing the form, save your changes, and you may choose to download, print, or share the form as needed for submission. Ensure you send it to the appropriate address or email it to the DC Health Link as instructed.

Complete your Decline Medicaid Coverage Form online today to ensure proper handling of your request.