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Is PERSON 3 currently living in a DJJ group home 15. Does PERSON 4 want help paying for medical bills from the last 3 months 37. YEARLY INCOME Complete only if PERSON 4 s income changes from month to month. If you have more than four people to include ask for and complete DHHS Form 3400-01 for each additional person. STEP 3 1. Are you or is anyone in your family American Indian or Alaska Native If NO skip to Step 4. YES. If YES ask for and comple...
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How to fill out dhhs form 3400 a
How to fill out dhhs form 3400 a:
01
Begin by reviewing the form instructions provided by the Department of Health and Human Services (DHHS) to ensure you understand the purpose and requirements of the form.
02
Gather all necessary information and supporting documents that may be required to complete the form accurately. This may include personal identification information, financial records, medical or healthcare documentation, and any other relevant information.
03
Read through each section of the form carefully. Follow the instructions provided for each field and provide accurate and complete information as requested. Take your time to ensure accuracy and double-check all entries before proceeding.
04
If you encounter any specific guidelines or special instructions within the form, make sure to follow them precisely to avoid any delays or complications with your submission.
05
Once you have completed all the necessary sections, review the entire form again to ensure you have not missed any required information or made any mistakes. Correct any errors or omissions before finalizing the form.
06
Sign and date the form as required by DHHS. If any additional signatures are needed, make sure to obtain them before submitting the form.
07
Make a copy of the completed form with all supporting documents for your records.
08
Submit the filled-out form and any additional requested documentation to the designated DHHS office or as instructed in the form instructions. Ensure you meet any specified deadlines for submission.
Who needs dhhs form 3400 a:
01
Individuals who are applying for a specific program or service provided by the Department of Health and Human Services may need to fill out form 3400 a.
02
This form is often required for applications related to healthcare assistance, financial assistance, social services, or other DHHS programs.
03
The specific eligibility requirements and guidelines for needing form 3400 a may vary depending on the program or service being applied for.
04
It is recommended to check with the DHHS or the specific program's requirements to determine if form 3400 a is needed in your particular situation.
Video instructions and help with filling out and completing dhhs form 3400 a
Instructions and Help about scdhhs form 3400c
Hello and welcome to the North Carolina Medicaid managed care webinar Before we get started with the presentation I'll share some quick housekeeping We've had such high interest in this webinar that we're broadcasting it live This means you'll need to be sure to have the audio on your computer turned on otherwise you will not be able to hear the webinar If you do not have audio on your computer you can call this bridge line 5 – 6 - 2 2 - 4 - 7 - 8 - 3 - 2 - 1 That bridge line again is 562-247-8321 You'll need to type in this access code 613-403-382 Again that access code 613-403-382 If you experience any technical difficulties please visit GoToMeeting and click support or call 1-888-646-0014 All attendees will be muted during the presentation If you have any questions please type them directly into the questions box in the toolbar at the side of your screen At the end the presentation we will open for Q&As and answer the questions that were submitted For future reference and for those who weren't able to attend we will email a link to the recording of today's presentation as well as post it on the Medicaid transformation page Please note the documents that will be reviewed during the presentation are posted on the North Carolina Medicaid playbook site, and you can see those URLs on the bottom of the screen You can click to the bottom of that screen that has the URLs Today's presentation will cover the North Carolina Medicaid managed care transition and its impact on beneficiaries the timeline for Open Enrollment and what to expect in terms of communication — beneficiaries and how you can partner with the enrollment broker to educate beneficiaries Now I'd like to introduce you to our panel of speakers We have Dave Richard Deputy Secretary Medicaid Sandy Terrell Director of Benefits and Services Medicaid and Eric Rubin Division President for Health Services at MAXIMUS I'll now turn it over to Dave to begin the presentation Good afternoon everybody I'm glad you could join us today We're — excited to have this conversation with you So we're going to start with a little of sort of level setting for everyone and then get into more detail about how the enrollment broker process will work and the — as we're moving forward But I'm going to do a little of just a level setting for folks about where we are in managed care and with what that looks like, so we're all using the same terminology So the first thing we always want to start with is the vision that North Carolina HHS has for our managed care transformation I jokingly say to folks often is that there a lot of vision statements that are sitting around offices that people don't look at This one at HHS we spend a lot of time thinking about it — it's really what what we're trying to achieve inside managed care And I'll read it because I think it's important for people to hear it is that we're improving the health and well-being of North Carolinians through an innovative whole person-centered and well...
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What is dhhs form 3400 a?
DHHS Form 3400A is a form used by the U.S. Department of Health and Human Services (HHS) to collect information from individuals who are applying for benefits under the Social Security Act. The form collects information such as name, address, Social Security number, and other information needed to determine eligibility for benefits.
Who is required to file dhhs form 3400 a?
DHHS Form 3400a is typically completed by employers for reporting work-related injuries and illnesses to the U.S. Department of Labor's Occupational Safety and Health Administration (OSHA).
What is the purpose of dhhs form 3400 a?
The purpose of DHS Form 3400a is to provide a standardized form for completing the required reporting of suspected child abuse and neglect. The information gathered on this form is used to document and investigate reports of child abuse and neglect. The form is used by mandated reporters, such as teachers, doctors, social workers, and other professionals, to provide specific information about the suspected abuse or neglect.
What information must be reported on dhhs form 3400 a?
DHHS Form 3400A is a document used to provide information about a child who may have suffered abuse or neglect. It is used by state child protective services to document the reporting of suspected abuse, neglect, or exploitation of a child. The form requires information such as the name and contact information of the reporter, the name and contact information of the child, a description of the incident, and any other information that may be relevant.
When is the deadline to file dhhs form 3400 a in 2023?
The deadline to file DHHS form 3400a in 2023 has not yet been announced. Please refer to the DHHS website for the most up-to-date information.
How to fill out dhhs form 3400 a?
DHHS Form 3400-A is a document used to provide information about your household's income and expenses when applying for various benefits and assistance programs administered by the Division of Social Services under the North Carolina Department of Health and Human Services. Here are the steps to fill out the form:
1. Obtain a copy of DHHS Form 3400-A: You can either download the form from the North Carolina Division of Social Services website, pick up a physical copy at a local DHHS office, or request one be mailed to you.
2. Start with the applicant information: Provide your full name, Social Security Number (SSN), date of birth, and your mailing address.
3. Fill in the information about other household members: List the names, SSNs, and relationships for all individuals living in your household, including yourself.
4. Complete the "Income" section: Provide details about the income received by you and the other household members listed. Include all sources of income such as employment wages, self-employment income, social security benefits, retirement/pension, child support, alimony, unemployment benefits, etc. Indicate how frequently you receive each type of income (weekly, monthly, etc.) and the amount before any deductions.
5. List your allowable expenses: In this section, you need to provide information about your allowable expenses. These include rent/mortgage payments, utilities (electricity, gas, water, etc.), child care expenses, medical expenses that are not covered by insurance (include premiums, copays, etc.), child support payments you make, court-ordered garnishments, and other necessary expenses. Make sure to list the amount you pay for each expense and the frequency (weekly, monthly, etc.).
6. Provide the information on any additional deductions: If your household has any additional deductions such as childcare tax credits, elderly or disabled medical expenses, etc., list them in this section.
7. Sign and date the form: Now, review the completed form thoroughly to ensure all information is accurate and up-to-date. Sign and date the form.
8. Submit your completed form: Make a copy of the filled-out form for your records before mailing it or delivering it in person to your local DHHS office. Keep in mind that some DHHS offices may require appointments before accepting walk-in submissions.
It's important to note that the instructions provided here are a general guide for filling out DHHS Form 3400-A. Make sure to carefully read the instructions provided with the form itself and any additional guidance from the North Carolina Division of Social Services.
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