Dhs 1179a 2025

1. Click ‘Get Form’ to open the dhs 1179a in the editor.
2. Begin by filling in the 'Primary Individual Name' and 'Date of Birth' fields. Ensure accuracy as this information is crucial for identification.
3. In Section 1, indicate if you are terminating medical assistance by providing the effective date and reason for termination.
4. For name changes in Section 2, complete both 'From' and 'To' fields, attaching any necessary legal documents.
5. Update your address and phone number in Section 3. Remember that these changes apply to all household members unless specified otherwise.
6. If applicable, report pregnancy details in Section 4, including expected due date and number of babies.
7. In Section 5, provide information about any third-party liability coverage, attaching a copy of your insurance card if available.
8. Complete Sections 6 through 8 as needed, ensuring all relevant changes are documented accurately before submitting.

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