Dhs 3876-2026

1. Click ‘Get Form’ to open the DHS 3876 application in the editor.
2. Begin by reading the Notice of Privacy Practices and Rights in Attachment A. Tear off and keep these notices for your records.
3. Fill in personal information in Section 1, including your first name, last name, date of birth, and Social Security number if applicable. If you need more space, write additional details on a separate piece of paper.
4. In Section 3, provide your current address and contact information. Ensure accuracy as this will be used for correspondence regarding your application.
5. Complete Section 4 by listing others living with you who are applying for health care coverage. Include their names, dates of birth, and relationships to you.
6. Review all sections carefully to ensure all questions are answered accurately before signing and dating the application at the end.
7. Attach any required proofs as specified in the instructions. Remember to send copies only; do not send original documents.
8. Submit your completed application via fax or mail it to your county or tribal agency as listed in Attachment C.

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