Michigan retroactive medicaid: Fill out & sign online

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Click ‘Get Form’ to open the dhs retroactive application in the editor.
Begin by entering the months for which you have unpaid medical bills. Fill in the first, second, and third month fields with the respective dates.
For each month listed, provide the names of family members living with you and indicate if they have unpaid medical expenses by checking 'yes' or 'no'.
Answer questions regarding hospital stays for family members on the last day of each month. If applicable, enter their names.
Detail any significant changes during each month, such as births or changes in employment status, along with the dates of these changes.
Attach proof of income for each month applied for and complete sections regarding child support, guardianship expenses, alimony, and other financial obligations.
Finally, certify that all information is accurate by signing and dating the form before submitting it through our platform.

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