The Department of Social and Health Services (DSHS) provides a number of forms to help Washington residents apply for benefits and services. One such form is the DSHS 13 836, which can be used to request medical care, cash assistance, and other benefits. This form is available in both English and Spanish, and can be filled out online or printed out for submission. In this blog post, we'll provide an overview of the DSHS 13 836 form, including what it is used for and how to complete it. We'll also provide links to more information about specific benefits that can be requested with this form.
| 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