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Kentucky Employees Health Plan Department of Employee Insurance Enrollment Information Branch keep.KY.gov 18885818834MEDICAID ELIGIBILITY/TERMINATION FORM To be used to verify eligibility for coverage

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How to fill out medicaid eligibilitytermination form

01

Obtain the Medicaid eligibility termination form from your state's Medicaid office or website.

02

Fill in your personal information accurately, including your name, address, and Medicaid ID number.

03

Indicate the reason for terminating your Medicaid eligibility, such as obtaining other health insurance coverage.

04

Sign and date the form to certify the information provided is true and accurate.

05

Submit the completed form to the Medicaid office either in person, by mail, or online, depending on the instructions provided.

Who needs medicaid eligibilitytermination form?

01

Individuals who no longer qualify for Medicaid benefits and need to officially terminate their eligibility.

02

Anyone who has obtained other health insurance coverage and wishes to discontinue their Medicaid benefits.

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What is medicaid eligibilitytermination form?

Medicaid eligibility termination form is a form used to report the termination of Medicaid eligibility for an individual.

Who is required to file medicaid eligibilitytermination form?

The individual or their authorized representative is required to file the medicaid eligibility termination form.

How to fill out medicaid eligibilitytermination form?

The medicaid eligibility termination form can be filled out by providing the required information about the individual whose eligibility is being terminated.

What is the purpose of medicaid eligibilitytermination form?

The purpose of the medicaid eligibility termination form is to inform the Medicaid program about the termination of eligibility for an individual.

What information must be reported on medicaid eligibilitytermination form?

The medicaid eligibility termination form must include the individual's name, Medicaid ID, reason for termination, and effective date of termination.

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