Get Dhs 1100b (rev. 12/2020) Page 1 Of 6 Supplemental Form For ...

Filling out the DHS 1100B (Rev. 12/2020) Supplemental Form is an important step for individuals applying for health coverage based on age, blindness, or disability. This guide will provide clear instructions on completing the form online, ensuring that your application process goes smoothly.

Follow the steps to successfully complete the DHS 1100B form.

1. Click ‘Get Form’ button to obtain the form and open it in your preferred online editor.
2. Begin filling out the Application Date field by entering the current date. Next, provide the Date Sent and Due Date as necessary; these should reflect relevant timelines for your application.
3. In the Name section, write your full name, ensuring to include first name, middle initial, last name, and suffix if applicable.
4. Complete the Address section with your current residence information. If you need more space, remember to attach a separate sheet.
5. For Section A, identify who needs long-term care (LTC) services by providing their first name, middle initial, last name, and suffix, followed by their date of birth. Indicate whether they have been certified as blind or disabled.
6. Specify where the LTC services are to be provided by checking the appropriate box and noting the address or facility name. Also, include the service start date.
7. Indicate the marital status by selecting the corresponding option and providing any required details for your spouse or dependents in Section B.
8. In Section C, detail income and assets as applicable. For each income type, check ‘Yes’ or ‘No’ and provide the monthly amounts where required. Repeat this for assets.
9. Complete health insurance and medical expenses questions, ensuring you provide needed details for types of coverage and any outstanding medical bills.
10. Read and sign the Certification and Authorization section. Ensure that the individual filling out the form is correctly noted and any additional signatures are included.
11. Finally, after reviewing all the information for accuracy, save the changes you have made. You can then download, print, or share the completed form as needed.

Start completing your DHS 1100B supplemental form online today for a smooth application process.