Insurance Assistance Recertification 2026

1. Click ‘Get Form’ to open the Insurance Assistance Recertification in the editor.
2. Begin with Section I: Enrollee Information. Fill in your DAP ID, last name, first name, and full middle name. Enter your month and year of birth, home address (no PO Boxes), county, and mailing address if different.
3. Provide your contact information by entering both home and other phone numbers. Specify your ethnicity and race by checking the appropriate boxes.
4. Move to Section II: Eligibility Information. List all household members along with their relationship to you, gender, date of birth, place of employment or income source, and estimated yearly gross income.
5. In Section III: Benefits Information, check the boxes regarding Medicaid and Medicare coverage as applicable.
6. Complete Section IV: Clinical Information with details about your current disease stage and relevant medical history as required by your physician.
7. Finally, review Section V: Certification/Consent. Ensure all parties sign where indicated before submitting the form through our platform for processing.

Start using our platform today to easily complete your Insurance Assistance Recertification form online for free!