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Get Dsh-001 2015-2026
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How to fill out the DSH-001 online
The DSH-001 form is essential for determining eligibility for Disproportionate Share Hospital services and Medicaid/KCHIP. This guide provides clear, step-by-step instructions on how to fill out the form accurately and effectively.
Follow the steps to complete the DSH-001 form online.
- Click the ‘Get Form’ button to access the DSH-001 form and open it in your editor.
- Begin filling out Section 1: Individual Information. Provide the today's date, the patient's name, and contact details including street address, city, state, zip code, and if applicable, the social security number and date of birth.
- Indicate marital status and provide information regarding the spouse if applicable. Answer whether the patient is pregnant and provide details about residency status in Kentucky.
- List the household members, including their names, relationships, and ages in response to question 15.
- Fill out the income information in Section 1: Income information, including employer details, total gross monthly income, and any other income sources.
- Complete the insurance information section with relevant health or life insurance details, if applicable.
- Provide countable resources by indicating balances in bank accounts, stocks, bonds, and other investments.
- Answer questions in Section 2: Hospital Indigent Care Criteria to ensure all eligibility conditions are met.
- Certify the accuracy of the information by signing Section 3. Make sure to date the signature and provide details for the hospital employee if required.
- If refusing Medicaid, complete Section 4 by signing and dating the refusal.
- Complete Section 5 if the individual does not meet indigent care criteria and indicate the specific reasons.
- If needed, make a hearing request in Section 6. Sign, date, and provide the necessary details.
- Finally, save your changes, and proceed to download, print, or share the completed application as needed.
Complete your DSH-001 form online today to ensure eligibility for the necessary services.
A DSH percentage quantifies the portion of a hospital's patients who are eligible for Medicaid or are uninsured. This percentage plays a vital role in determining the level of federal funds allocated to aid these institutions. By leveraging the DSH-001 feature, you can accurately assess your facility's DSH percentage and explore strategies to enhance its funding rate.