Definition & Meaning of the DHS-1004 Form
The DHS-1004, or Health Care Coverage Supplemental Questionnaire, is a form utilized by the Michigan Department of Health and Human Services (MDHHS). This form is essential for individuals applying for or renewing Medicaid or healthcare coverage. It specifically targets cases where applicants may qualify under disability or senior programs, such as those for the aged, blind, or disabled, which do not fall under the standard Modified Adjusted Gross Income (MAGI) criteria. The DHS-1004 form plays a critical role in clarifying asset and income details that are necessary for a comprehensive eligibility determination.
The form is designed to collect information that may not be included in the initial application (DCH-1426). This includes proof of income, assets, and signed declarations, which are crucial for assessing eligibility for various healthcare programs.
How to Fill Out the DHS-1004 Form
Filling out the DHS-1004 form requires careful attention to detail to ensure accurate information is provided. Here are the key steps to consider:
- Gather Necessary Documents: Before starting, collect all relevant documents, such as income statements, asset documentation, and any previous health coverage details.
- Complete Personal Information: Fill in your name, address, and contact information accurately. This section is vital for processing your application.
- Detail Income Sources: Clearly list all sources of income, including wages, Social Security benefits, and any other financial support. Be specific about amounts and frequency of payment.
- Declare Assets: Provide an honest account of your assets, including bank accounts, property, and investments. This information helps determine your eligibility for programs.
- Review and Sign: After completing the form, review all entries for accuracy. Sign and date the form to validate the information provided.
Who Typically Uses the DHS-1004 Form?
The DHS-1004 form is primarily used by individuals applying for or renewing Medicaid or healthcare coverage in Michigan. Specific groups that may find this form particularly relevant include:
- Seniors: Older adults who may qualify for specialized healthcare programs.
- Individuals with Disabilities: Those who require additional support due to physical or mental health conditions.
- Low-Income Families: Families with limited income who may need assistance in covering healthcare costs.
Additionally, caregivers and advocates supporting these individuals may also assist in completing the DHS-1004 form to ensure all necessary information is accurately reported.
Important Terms Related to the DHS-1004 Form
Understanding key terms associated with the DHS-1004 form can enhance comprehension and facilitate the application process. Here are some important terms:
- Medicaid: A state and federal program that provides health coverage to eligible low-income individuals.
- Eligibility Criteria: The specific requirements that applicants must meet to qualify for Medicaid or other health programs.
- Asset Verification: The process of confirming the financial assets of an applicant to determine eligibility.
Legal Use of the DHS-1004 Form
The DHS-1004 form is legally recognized as an official document for assessing eligibility for healthcare programs in Michigan. It is important to understand the legal implications of submitting this form:
- Accuracy is Crucial: Providing false information can lead to penalties, including loss of benefits or legal action.
- Confidentiality: Information submitted is protected under privacy laws, ensuring that personal data is handled securely.
Examples of Using the DHS-1004 Form
Real-world scenarios illustrate how the DHS-1004 form is applied:
- Case of a Senior Citizen: An elderly individual applying for Medicaid may need to fill out the DHS-1004 to clarify income from Social Security and assets from a home sale.
- Individual with a Disability: A person receiving disability benefits may use the form to provide additional documentation regarding medical expenses and other financial support.
Application Process & Approval Time for the DHS-1004 Form
The application process for the DHS-1004 form involves several steps:
- Submission: The completed form can be submitted online, by mail, or in-person at designated offices.
- Processing Time: Approval times can vary, but applicants may expect a response within thirty days, depending on the complexity of their case.
It is advisable to follow up if no response is received within the expected timeframe to ensure the application is being processed.
Required Documents for the DHS-1004 Form
When completing the DHS-1004 form, applicants must provide several supporting documents:
- Proof of Income: Recent pay stubs, tax returns, or Social Security statements.
- Asset Documentation: Bank statements, property deeds, and investment account statements.
- Identification: A government-issued ID or Social Security card may be required for verification purposes.
Having these documents ready can streamline the application process and reduce delays.
