Client Self-Attestation Form - dhss.delaware.gov - dhss delaware 2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by reading the introduction carefully. This section outlines the purpose of the form and your obligations regarding health insurance coverage.
3. In the required section, check the box to attest that you are exempt from the federal mandate or ineligible for Medicaid coverage. This is a crucial step for your application.
4. If applicable, move to the optional section where you can indicate your specific circumstance for exemption or ineligibility. Choose from the provided options or write your explanation in the space provided.
5. Fill in your name, date, and signature at the bottom of the form to validate your attestation.
6. Complete your contact information, including address and phone number, ensuring all details are accurate for follow-up.
7. Review all entries for accuracy before submitting. Use our platform’s editing tools to make any necessary adjustments easily.

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