Get WA DSHS 13-836 2008-2024

Family and Children s Medical Benefits Renewal This form is for renewal of medical benefits only. To apply for financial or food assistance contact your local DSHS Community Services Office CSO. Proof of earned income is copies of wage stubs or a statement from your employer. If you are self-employed you can provide a copy of last year s income tax return. Don t wait to call or return this renewal form because you don t have proof of income. Expenses paid by your household Total monthly child care cost you pay so you can work Total court ordered child support you pay each month DSHS 13-836 REV. To continue medical coverage you must complete a yearly renewal by doing one of the following Call the number on the attached letter to complete your renewal by telephone or Complete this form and mail it to us with current proof of income. CLIENT ID NUMBER Please Print* FIRST NAME LAST NAME MIDDLE INITIAL DATE OF BIRTH ADDRESS CITY STATE ZIP CODE MAILING ADDRESS IF DIFFERENT HOME PHONE NUMBER INCLUDE AREA CODE CELL PHONE NUMBER HOUSEHOLD Has anyone moved into your home in the past 12 months NAME Yes No GENDER Female U*S* Citizen Relationship to you SSN Male DATE MOVED OUT Did anyone in the household begin receiving private health insurance in the past 12 months If yes who Name of private health insurance All Monthly Earned or Unearned Income for your household. Employer Name/Phone Name of person with Income or Income Source Monthly Income before taxes or expenses Note Provide proof of your current income. Proof of earned income is copies of wage stubs or a statement from your employer. If you are self-employed you can provide a copy of last year s income tax return* Don t wait to call or return this renewal form because you don t have proof of income. Expenses paid by your household Total monthly child care cost you pay so you can work Total court ordered child support you pay each month DSHS 13-836 REV. To continue medical coverage you must complete a yearly renewal by doing one of the following Call the number on the attached letter to complete your renewal by telephone or Complete this form and mail it to us with current proof of income. CLIENT ID NUMBER Please Print* FIRST NAME LAST NAME MIDDLE INITIAL DATE OF BIRTH ADDRESS CITY STATE ZIP CODE MAILING ADDRESS IF DIFFERENT HOME PHONE NUMBER INCLUDE AREA CODE CELL PHONE NUMBER HOUSEHOLD Has anyone moved into your home in the past 12 months NAME Yes No GENDER Female U*S* Citizen Relationship to you SSN Male DATE MOVED OUT Did anyone in the household begin receiving private health insurance in the past 12 months If yes who Name of private health insurance All Monthly Earned or Unearned Income for your household. CLIENT ID NUMBER Please Print* FIRST NAME LAST NAME MIDDLE INITIAL DATE OF BIRTH ADDRESS CITY STATE ZIP CODE MAILING ADDRESS IF DIFFERENT HOME PHONE NUMBER INCLUDE AREA CODE CELL PHONE NUMBER HOUSEHOLD Has anyone moved into your home in the past 12 months NAME Yes No GENDER Female U*S* Citizen Relationship to you SSN Male DATE MOVED OUT Did anyone in the household begin receiving private health insurance in the past 12 months If yes who Name of private health insurance All Monthly Earned or Unearned Income for your household. Employer Name/Phone Name of person with Income or Income Source Monthly Income before taxes or expenses Note Provide proof of your current income. .