Get Fl Dh-3212 2016-2025

Filling out the FL DH-3212 is an essential step for individuals seeking benefits through the Medicaid Family Planning Waiver Program. This guide provides clear, detailed instructions to help you navigate the form effortlessly.

Follow the steps to complete your application.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Begin by entering your full name in the designated fields: first name, middle initial, and last name. Ensure that the information is accurate and spelled correctly.
3. Provide your residence address, including street number, apartment number (if applicable), city, county, state, and zip code. If your mailing address differs from your residence address, complete the mailing address section.
4. Answer the questions regarding previous services, with particular attention to questions 1 and 2, about hysterectomy and tubal ligation, as well as the date of your last menstrual period.
5. Indicate whether you wish to receive family planning services by selecting 'yes' or 'no' in question 3.
6. List all individuals residing in your home in question 4, starting with your name. Provide details such as relationships, tax filing status, claimed dependents, birth dates, race, sex, citizenship status, and any Medicaid application information.
7. Complete question 5 by reporting income information for all household members. This includes sources of income, gross amounts before deductions, and payment frequency.
8. Respond to questions 6-9 about your health insurance coverage. Provide the insurance company’s name and confirm if family planning is a covered benefit.
9. Review the certification and authorization section. Confirm all information is correct, then sign and date the form. It is necessary to sign after the date when you lost full Medicaid.
10. After completing the form, you may choose to save changes, download, print, or share the form according to your needs.

Start completing your FL DH-3212 online today to access the necessary benefits.