Get Dsh-001 (rev - Chfs Ky

This guide provides clear instructions on how to complete the DSH-001 form, which is essential for determining eligibility for the Disproportionate Share Hospital Program. Follow these steps to ensure accurate and efficient completion of the form online.

Follow the steps to successfully fill out the DSH-001 form.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. In Section I, enter individual information, including the patient’s name, address, date of birth, and contact details. Ensure that the Social Security Number is filled only if available, and explain its use to the patient.
3. Indicate the marital status and whether the patient is pregnant. Confirm if the patient is a resident of Kentucky and provide proof of residency if necessary.
4. List all household members along with their relationships and ages. This is essential for determining eligibility.
5. Provide comprehensive income information, including employment details and total gross monthly income. Also, document any other income sources.
6. Fill out the insurance information section, including policy details and the relation of the policyholder to the patient.
7. Report all countable resources, specifying bank accounts, savings, and investments. Remember that total resources can be reduced by unpaid medical expenses.
8. Complete Section II regarding indigent care criteria, ensuring that all conditions are met for qualification.
9. Sign and date the certification in Section III, confirming accuracy of the information provided and allowing the hospital to verify details.
10. If refusing to apply for Medicaid, ensure that the individual or their responsible party signs Section IV, acknowledging the refusal.
11. Complete any additional information required in Sections V, VI, and VII based on the individual's eligibility status and hospital determination.
12. Finally, review all entries for accuracy, save your changes, and you can download or print the completed form for sharing as necessary.

Complete your DSH-001 application online today to ensure timely processing of your eligibility.