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Get Wa Doh 345-214 2010
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How to fill out the WA DOH 345-214 online
Filling out the WA DOH 345-214 form is essential for accessing breast and cervical cancer treatment benefits. This guide will help you understand each component of the form and provide step-by-step instructions to complete it accurately and effectively.
Follow the steps to complete the WA DOH 345-214 form online.
- Click ‘Get Form’ button to obtain the form and open it in the editor.
- Enter your name in the designated fields: Last name, First name, and Middle Initial (MI). Ensure to print clearly for accuracy.
- Locate the field for BCCHP PRIME CONTRACTOR and fill in 'SPOK' as Spokane Regional Health District.
- Provide your BCCHP CLIENT ID #, ensuring that it is filled out accurately.
- Enter your date of birth in the format (mm/dd/yyyy) in the specified section.
- In the next section, input the date of diagnosis again in the format (mm/dd/yyyy).
- Fill in your case manager's name and contact details, including their phone number and fax number.
- Indicate whether you have signed the Client Consent Form by checking the appropriate box.
- Confirm your residency status in Washington State by checking 'Yes' or 'No.'
- Indicate your U.S. citizenship status by checking 'Yes' or 'No.'
- If applicable, confirm if you possess documents to show your status. Check 'Yes' or 'No' and list the documents if any.
- Provide the state or country of your birth as required.
- If you are not a U.S. citizen, enter your entry date into the U.S.
- Indicate if you have unpaid medical bills related to your diagnosis by selecting the appropriate response and months, if applicable.
- Review the information you have provided, affirm your understanding of the statements by signing, and entering the date below your signature.
- Specify the start date for coverage as needed.
- The case manager should sign and date the form.
- Once the form is fully completed, save changes, download, print, or share the form as appropriate.
Ensure that you complete and submit your documents online for optimal processing.
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