Get Hi Dhs1100a 2013-2026

The HI DHS1100A is an essential form used to apply for health coverage and financial assistance for health costs. This guide will provide a comprehensive overview of how to complete the form online, ensuring you understand each section and can successfully submit your application.

Follow the steps to complete the application successfully.

1. Click ‘Get Form’ button to obtain the form and open it in your editor.
2. Begin filling out the form by providing personal information. Input your first name, middle name, last name, and suffix. Include your home address, and check if you have an apartment or suite number to enter.
3. Continue with your city, state, zip code, and county. If you have a mailing address that differs from your home address, fill that in as well.
4. Enter your phone number and another phone number if applicable. Indicate whether you would like to receive information about your application via email and provide your email address if yes.
5. Specify your preferred language for communication and enter your date of birth. Choose your sex and enter your Social Security number. Indicate whether you are a U.S. citizen or national.
6. If you are not a U.S. citizen or national, provide your immigration status by filling in the document type and ID number. Answer the questions about your military service and if you are pregnant.
7. Indicate if you have any physical, mental, or emotional health conditions that affect your daily activities.
8. Proceed to Section 2 to provide information about your current job and income. If employed, describe your employer's name and address, phone number, and your wages or tips.
9. If you have multiple jobs, fill out additional job information as required. If you're self-employed, please provide your net income from self-employment.
10. List any other sources of income you receive, indicating the amount and frequency.
11. In Section 3, indicate your current health coverage status and check any applicable existing health plans.
12. Finish the form by reading and signing the application, acknowledging the statements made regarding true information and eligibility.
13. Date your application and prepare to mail it to the specified addresses provided in the instructions.

Complete your HI DHS1100A application online now to access potential health coverage and financial assistance.