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DPHHSSLTC163 (New 2/09; Rev 7/14, 11/15, 4/17)STATE OF MONTANA Department of Public Health and Human ServicesPersonal Assistance Services/Community First Choice Agency Admit AB CFC SD CFC ABBAS SPAS

How to fill out dphhs-ma-136

How to fill out dphhs-ma-136

1. To fill out dphhs-ma-136 form, follow the steps below:
2. Start by entering your personal information such as your full name, address, and contact details.
3. Provide your social security number, date of birth, and gender.
4. Next, you will need to indicate your marital status and provide details about your spouse if applicable.
5. Fill in information about your household members, including their names, relationship to you, and their financial information if they are contributing to the household income.
6. Indicate if you or any household members have health insurance coverage and provide the necessary details.
7. If you are applying for Medicaid specifically, fill out the relevant sections with information about your income, assets, and expenses.
8. Finally, review the form to ensure all the information you provided is accurate and complete. Sign and date the form, and submit it as directed.

Who needs dphhs-ma-136?

1. The dphhs-ma-136 form is needed by individuals who are applying for Medicaid or other healthcare programs administered by the Department of Public Health and Human Services (DPHHS) in Montana. This form is used to assess eligibility for these programs and to gather necessary information about the applicant and their household.

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What is dphhs-ma-136?

dphhs-ma-136 is a specific form used for reporting certain health and human services information as required by the Department of Public Health and Human Services.

Who is required to file dphhs-ma-136?

Entities or individuals who provide specific health services or receive funding from the Department of Public Health and Human Services may be required to file dphhs-ma-136.

How to fill out dphhs-ma-136?

To fill out dphhs-ma-136, gather the necessary data as outlined in the form's instructions, complete each section carefully, and ensure all information is accurate before submitting.

What is the purpose of dphhs-ma-136?

The purpose of dphhs-ma-136 is to collect data for tracking, compliance, and funding allocation related to health and human services programs.

What information must be reported on dphhs-ma-136?

The information reported on dphhs-ma-136 typically includes service details, financial data, and demographic information regarding the population served.