FORMS
TEMPLATE
REQUESTING INFORMATION
100

What is the form number of the Request for Information?

DHB-5097 or 5097

100

True or False:

The template should be filled out with all information on all HH members whether they are applying or not.

False:

Most questions only need information related to applicants.


100

True or False:

We always need to request residency verification.

False:

We accept client statement if no verifications are found.

200

What is the DHB-5200?

Medicaid Application, application for health coverage

200

True or False:

Items like retro and emergency can be left of the template if they do not apply to your application

False:

ALL information must be filled in on the template.

200

How many calendar days must be between the first notice (5097) and the second notice?

12

300

What is the form we send with the DHB-5097 to get resource information?

Appendix D, DHB-5202C

300

What is the first item on the documentation template?

CHANGE CASE OWNER NAME!

300

What is the time period for requesting medical bills for a deductible?

24  MONTHS or month of app minus 2 years

400

What is the number of the form used for application approvals?

5003/DHB-5003

400

At application, where does documentation need to be entered?

In compass and on all applications.

400

True or False:

If the 12th day falls on a weekend or holiday, the 2nd notice can be sent on the next business day.

True

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