Dhs form dco 662 2025

1. Click ‘Get Form’ to open the DHS Form DCO 662 in the editor.
2. Begin by filling out the Applicant Information section. Enter your last name, first name, middle initial, sex, social security number, address, city, state, and zip code.
3. Indicate whether you have health insurance other than Medicare. If yes, attach proof of coverage or complete sections B, C, and D. If no, skip to Section F.
4. In the Policyholder Information section (B), provide the policyholder's last name, first name, middle initial, social security number, address, city, and state.
5. Next, fill out the Insurance Information section (C) by entering the insurance company name, policy number, effective dates of the policy, claims office address and city.
6. Check all applicable types of benefits or coverage in section C. Ensure at least one option is selected.
7. List all individuals covered by the policy in section D by providing their last name, first name, middle initial, relationship to you and their SSN or Medicaid number.
8. Add any comments in section E if necessary. Finally, provide a telephone number where you can be reached in section F.
9. Sign and date the authorization statement at the bottom before submitting your completed form.

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