Get Client Self-attestation Form - Dhss.delaware.gov - Dhss Delaware

Filling out the Client Self-Attestation Form is a straightforward process that allows individuals to confirm their ineligibility or exemption from federal health insurance requirements. This guide will walk you through each step to ensure a smooth completion of the form.

Follow the steps to successfully complete your form online.

1. Press the ‘Get Form’ button to access the Client Self-Attestation Form and open it for editing.
2. Begin by carefully reading the introductory section of the form to understand the purpose and the importance of completing this form accurately.
3. In the first section labeled 'Required,' confirm your status by checking the box to attest to your exemption from the federal mandate to have health insurance or your ineligibility to obtain Medicaid coverage.
4. In the next section labeled 'Optional,' consider providing information about why you are ineligible or exempt. Check one or more circumstances that apply to you, such as whether coverage is unaffordable or if your household income is below the filing threshold.
5. Complete the affirmation statement by printing your name and the date in the designated fields. This confirms that the information provided is true to the best of your knowledge.
6. Sign the form where indicated to authenticate your submission.
7. Provide your contact information, including your address, phone number(s), and email, ensuring all details are accurate for any follow-up.
8. If necessary, use the provided space to include any additional information that may be relevant.
9. Once all sections are completed, save your changes, and download, print, or share the form according to your needs.

Get started on completing your Client Self-Attestation Form online today!