Life can often lead individuals down a path where assistance is necessary to maintain a basic standard of living, notably when it comes to securing food and healthcare for families. The DSHS 13-836 form plays a crucial role in this aspect, as it is specifically designed for individuals needing to renew their medical benefits within the framework of Family and Children’s Medical Benefits offered through the Department of Social and Health Services (DSHS). With an annual renewal requirement, this documentation process is critical for those relying on such support to ensure that there is no interruption in their medical coverage. The form facilitates a straightforward renewal process by offering two options: a telephone renewal or a mail-in option with current proof of income. It meticulously captures essential data, such as personal identification information, household changes, and income details, all while emphasizing the necessity of providing up-to-date proof of income—even suggesting alternative documents for the self-employed or those unable to immediately provide traditional proofs. This approach underscores the DSHS's commitment to maintaining essential services for families and individuals, highlighting the importance of timely and accurate submissions to continue receiving benefits that significantly impact their well-being.
| Question | Answer |
|---|---|
| Form Name | Dshs 13 836 Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | dshs renewal, dshs 13 836 blank, dshs 13 836, dshs washington state renew ebt |
Family and Children’s
Medical Benefits Renewal
This form is for renewal of medical benefits only.
contact your local DSHS Community Services Office (CSO).
To continue medical coverage you must complete a yearly renewal by doing one of the following:
•Call the number on the attached letter to complete your renewal by telephone; or
•Complete this form and mail it to us with current proof of income.
CLIENT ID NUMBER
Please Print.
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FIRST NAME |
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LAST NAME |
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MIDDLE INITIAL |
DATE OF BIRTH |
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ADDRESS |
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CITY |
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STATE |
ZIP CODE |
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MAILING ADDRESS (IF DIFFERENT) |
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CITY |
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STATE |
ZIP CODE |
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HOME PHONE NUMBER |
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CELL PHONE NUMBER |
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EMAIL ADDRESS |
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INCLUDE AREA CODE |
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INCLUDE AREA CODE |
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HOUSEHOLD |
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Has anyone moved into your home in the past 12 months? |
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Yes |
No |
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NAME |
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DATE OF BIRTH |
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GENDER |
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SSN |
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Female |
Male |
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U.S. Citizen |
Yes |
No |
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Relationship to you |
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Has anyone moved out of your home in the past 12 months? |
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Yes |
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No |
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NAME |
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DATE MOVED OUT |
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Did anyone in the household begin receiving private health insurance in the past 12 months? |
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Yes |
No |
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If yes, who |
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Name of private health insurance |
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All Monthly Earned or Unearned Income for your household. |
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Name of person with Income |
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Employer (Name/Phone) |
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Monthly Income |
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or Income Source |
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(before taxes or expenses) |
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Note: Provide proof of your current income. Proof of earned income is copies of wage stubs, or a statement from your employer. If you are
return this renewal form because you don’t have proof of income.
Expenses paid by your household
Total monthly child care cost you pay so you can work |
$ |
Total court ordered child support you pay each month |
$ |
DSHS