Medicaid And Kid Care Chip Renewal Form Page 4
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12Tell us about anyone who has other health insurance coverage
Include anyone you listed in Section 3 and anyone who is applying for health insurance coverage.
Name of insurance company:
Type of insurance:
Medicare
Tricare
Veteran's health coverage
Other insurance
Employer Sponsored Insurance
List everyone who is on this policy:
Name of insurance company:
Type of insurance:
Medicare
Tricare
Veteran's health coverage
Other insurance
Employer Sponsored Insurance
List everyone who is on this policy:
If anyone on this form is offered health insurance through a job, check here
If this a State of Wyoming employee benefit plan, check here
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Tell us more about the people listed on this form
If anyone who is renewing or applying has a physical, mental, or emotional health condition that causes limitations in
activities (like bathing, dressing, daily chores, etc.) or live in a medical facility or nursing home, write his or her name here.
Name (first, middle, last & suffix):
Name (first, middle, last & suffix):
If anyone who is renewing or applying for health insurance coverage is between the ages
of 18 and 26 and was in foster care at age 18, write his or her name here.
Name (first, middle, last & suffix):
Name (first, middle, last & suffix):
If anyone listed on this form (whether renewing or applying for health insurance coverage or not)
is pregnant, write her information below.
Name (first, middle, last & suffix):
How many babies are expected?
What is the expected delivery date?
Name (first, middle, last & suffix):
What is the expected delivery date?
If anyone listed on this form is currently receiving treatment for breast or cervical cancer, write their name
here. If so, please provide current verification from your treating provider.
Name (first, middle, last & suffix):
Name (first, middle, last & suffix):
If anyone who is renewing or applying is an American Indian or Alaska Native, check here
and fill out Attachment B on page 10.
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Questions?
Call our customer service center at 1-855-294-2127 (TTY/TDD: 1-855-329-5204).
The call is free. You can call 7:00 a.m. to 6:00 p.m. Monday to Friday. Or visit
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