Get Form H1855

Filling out Form H1855 correctly is essential for individuals seeking Medicaid benefits for breast and cervical cancer. This guide provides clear, step-by-step instructions to help users navigate the form with ease.

Follow the steps to complete the Form H1855 online.

1. Click ‘Get Form’ button to access and open the form in an online editor.
2. Begin by providing your personal information, including your client name, address, and contact details. Ensure that all information is accurate and up-to-date.
3. In the section related to your current Medicaid status, indicate whether you are currently receiving benefits and if you are seeking re-evaluation for breast or cervical cancer treatment.
4. For applicants who have had a diagnosis or treatment for breast or cervical cancer, provide details regarding the date of diagnosis and treatment confirmation by a healthcare provider.
5. If applicable, include information about any additional health insurance you have. Attach a copy of both the front and back of your insurance card.
6. Once you have completed all required fields, review your answers for accuracy. Make any necessary corrections before proceeding.
7. Once satisfied with the information provided, you can save your changes, download the completed form for your records, print it, or share it as instructed.

Take action now and ensure your Medicaid benefits are in place by completing Form H1855 online.