Form 403 - Diamond State Health Plan - Application For Health Insurance

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Diamond
State
APPLICATION FOR HEALTH INSURANCE
Health
Plan
Complete and sign this application form to apply for the Delaware
Last Name
First Name
M.I.
Healthy Children Program, Medicaid, or the Medicare Beneficiary
Savings Program.
Street Address
Apt. No.
Return this application within 30 days of the date you asked for
health insurance. If you do not, this may change the date your
health insurance will start.
City
State
Zip Code
We need you to give us proof of the following items:
One Month of Family Income (pay stubs, award letters)
Self-employment (complete tax return including all schedules)
Do you plan to stay in Delaware?
Lawful alien status (copy of front/back of card, papers)
Daytime Telephone Number
Birth Date (for newborns only)
Pregnancy
Mailing Address (if different from above)
Copy of Medicare card
Pregnant women only need to state family income and provide
medical proof of pregnancy. Other verification must be given
Please list any other names that you may have used
within 30 days.
Do not wait to send in your application if you do not have all the
For Office Use Only
information. We will review your application and if more
Date of Inquiry
Referral Source
information is needed, we will tell you. Once we get all the
information we need, a written notice of decision will be sent to
you.
?
If you have questions, please call:
Applicants who are approved for Medicaid’s Diamond State
Health Plan or the Delaware Healthy Children Program must
Division of Medicaid & Medical Assistance
1-800-372-2022
enroll in a managed care organization. An enrollment information
Health Benefits Manager
1-800-996-9969
packet that explains benefits will be sent to you. Applicants who
are approved for the Medicare Beneficiary Savings Program
Remember to sign and date the back of this application
cannot enroll in a managed care organization.

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