Get Hfs 243c Form

The Hfs 243c Form, also known as the request for medical benefits for another family member(s), is essential for individuals seeking to extend medical coverage to additional family members. This guide provides step-by-step instructions on how to fill out the form online accurately and efficiently.

Follow the steps to complete the Hfs 243c Form online.

1. Press the ‘Get Form’ button to obtain the Hfs 243c Form and open it in the designated editor.
2. Begin by filling in the case name, address, phone number, and case number at the top of the form. Ensure all information is accurate as it will be used throughout the process.
3. In the section labeled ‘I would like to request medical benefits for the person(s) named below,’ list the names, sex, birth dates, and Social Security numbers of each person you are requesting benefits for. If Social Security numbers are not available, attach proof of application.
4. Specify the relationship of each person to you, and indicate whether they are an Alaska Native or American Indian if applicable.
5. If any of the persons listed are under 19 years old, enter the names of the mother and father. Include whether they have received any medical care in the past three months and if you want the state to cover those costs.
6. Indicate if any person is pregnant and attach a doctor's statement if applicable.
7. If the persons listed are covered by health insurance, provide the details including insurance start and end dates, coverage specifics, insurance company name, policyholder details, and any relevant group numbers.
8. Complete the income section by detailing any income received by the persons listed, including employment and any additional income sources. Attach relevant documentation such as pay stubs or self-employment records.
9. Review the section regarding child support or spousal support obligations. If applicable, provide amounts and attachment proof.
10. Conclude by signing and dating the form to affirm that all provided information is accurate to the best of your knowledge.
11. Once all fields are filled out thoroughly, save changes, and prepare to download, print, or share the completed form as necessary.

Take the next step and fill out your Hfs 243c Form online today.