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How to fill out the DSH-001 online
The DSH-001 form is essential for individuals seeking eligibility for Disproportionate Share Hospital services or those who may qualify for Medicaid or KCHIP. This guide provides a clear description of how to fill out the form online, ensuring a seamless process for all users.
Follow the steps to complete the DSH-001 form.
- Click 'Get Form' button to obtain the DSH-001 and open it in your preferred online editing tool.
- Begin by filling out Section 1: Individual Information. Input the patient's name, today's date, and address details. Ensure the city, state, and zip code are correctly entered.
- Next, provide the patient's social security number and date of birth. Note that the social security number is not mandatory and is only used to assess current Medicaid status.
- Indicate the patient's sex along with the dates when hospital services were provided. Additionally, specify marital status and if applicable, the name of the spouse.
- Answer the question regarding pregnancy status and confirm if the patient is a resident of Kentucky.
- List the names, relationships, and ages of each person living in the household in question 15. This information is crucial for determining the household income.
- Complete the income information section, detailing total gross monthly income and any other relevant financial data.
- Fill in Section 18 regarding insurance, including details of health or life insurance policies. Be sure to provide the name of the policyholder and any other necessary insurance details.
- In Section 19, list countable resources such as bank accounts and investments, along with their respective balances.
- Approach Section 3: Certifying Accuracy of Information. Ensure all data filled is accurate and sign where indicated to certify correctness.
- Finally, review the entire form for completeness and accuracy. Once satisfied, you can save your changes, download a copy, print it, or share the form as needed.
Complete your documents online to ensure timely processing and eligibility determination.
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To speak with someone at the Department of Human Services in Illinois, you can call their customer service line or visit a local office. Make sure to have your case details handy for more efficient assistance. If you encounter difficulties navigating their system, referring to the DSH-001 platform can help clarify processes. Uslegalforms also offers insights and tools to help you prepare for your conversation with DHS.
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