Appendix K fi AH3-R Renewal Form - 2014-07-14.pdf-2026

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The document is a renewal form for HUSKY Health, which includes Medicaid and CHIP coverage. It outlines the process for renewing health coverage, including options to renew online, by phone, by mail, or in person. The form requires detailed information about household members, income, tax filing status, and any changes in circumstances. It emphasizes the importance of returning the form by a specified deadline to maintain coverage and provides contact information for assistance.

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Click ‘Get Form’ to open it in the editor.
Begin by reviewing all questions on the form. Ensure you understand what information is required for each section.
Fill in your contact information accurately, including your name, address, and phone number. Make sure to correct any wrong or missing details.
Provide tax information for each household member who files taxes. Indicate if they are married and list dependents as necessary.
In Section 3, list all individuals in your household who currently receive HUSKY Health coverage and indicate their immigration status.
Complete Sections regarding employment and income. Include details about job titles, employers, and income amounts.
Sign the form in Section 9 to confirm that all provided information is accurate and complete before submission.
Return the completed form by the specified deadline to avoid losing coverage.

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