Application for disproportionate share hospital program dsh and medicaid kchip screening form 2013-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Section 1: Individual Information. Fill in today's date, patient’s name, address, and contact details. Ensure accuracy as this information is crucial for eligibility determination.
3. Complete the Social Security Number and Date of Birth fields. Note that providing a Social Security Number is optional but can help determine Medicaid status.
4. Indicate marital status and whether the patient is pregnant. If pregnant, refer them to DCBS for Medicaid eligibility.
5. List all household members in question 15, including their names, relationships, and ages. This helps assess family size for income limits.
6. Proceed to Section 17 for income information. Accurately report total gross monthly income from all sources.
7. In Section 18, provide insurance details if applicable. This includes health/life insurance information which may affect eligibility.
8. Review all sections carefully before submitting your application to ensure completeness and accuracy.

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