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Click ‘Get Form’ to open the dhs 0415h form in the editor.
Begin with Section 1: Contact Information. Fill in your name, select your role (Applicant, Caseworker, or Other), and provide your phone number and email address.
Move to Section 2: Status of Insurance. Check all applicable boxes regarding your insurance status, such as whether you have active insurance or if it has changed.
In Section 3: Policy 1 Information, enter details about the first insurance policy. Include the insurance company name, policy holder’s name, policy ID number, Social Security number, date of birth, and type of policy.
List all individuals covered under Policy 1 who are applying for benefits by entering their names and dates of birth.
Repeat Section 4 for Policy 2 Information if applicable. Follow the same format as Policy 1.
Complete Section 5 regarding possible premium reimbursement by indicating whether you pay for any part of your health insurance premium.
Use Section 6 for any additional information about your current or recent insurance coverage that may be relevant.
Finally, ensure you attach copies of your insurance cards (front and back) before submitting the form to your caseworker.
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Documents that Establish Both Identity and Employment Authorization U.S. Passport or U.S. Passport Card. Permanent Resident Card or Alien Registration Receipt Card (Form I-551) Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine-readable immigrant visa.
What documents prove DHS work authorization?
Having a restricted social security card means youll need additional documentation from the Department of Homeland Security (DHS) showing youre legally approved to work in the U.S.
What is a DHS privacy waiver form?
This Directive establishes the Department of Homeland Security (DHS) responsibilities and policies for the Forms Management Program. It outlines the scope, authorities, responsibilities, policies, and requirements for the management of forms within DHS.
What does DHS mean on my social security card?
On March 1, 2003, USCIS assumed responsibility for the immigration service functions of the federal government. The Homeland Security Act of 2002 dismantled the Immigration and Naturalization Service (INS) and separated the agency into three components within the Department of Homeland Security (DHS).
What is a DHS authorization form?
Use this form to authorize the U.S. Department of Homeland Security (DHS) to disclose information and/or records about you to a third party. Taking this action is entirely voluntary; you are under no obligation to consent to the release of your information to any third party.
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