Form 295W PDF Details

The IRS Form 295W is a report required to be filed by all Applicable Large Employers (ALEs) with at least 50 full-time employees, including full-time equivalent employees. The purpose of the form is to collect information on the employer's health care coverage offerings. This information is used to determine whether an ALE owes a penalty for not providing affordable and minimum value health coverage to its employees. Let's take a closer look at what is required on Form 295W and how it impacts your business.

QuestionAnswer
Form NameForm 295W
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesAlabama, medicaid change address, medicaid change of information form, how to change address on medicaid

Form Preview Example

Alabama Medicaid Agency’s Recipient Change Report Form

Name_________________________________________________________

MEDICAID #______________

 

Address_______________________________________________________

Home Phone____________________

City/County/State/Zip________________________________________

Other Phone____________________

Is this a new address? Yes

No If Yes, Date Moved_______________________________________

Check the items that you have changes for. (There are more items listed on the back of this form.) NOTE: Your signature is required on the back of this form.

Marital Status Changes. Date of change_________________________

 

New marital status:

Married

Divorced

Separated

Widowed

If you checked Married, please complete the following:

 

 

Name of Spouse_____________________________________________________________________________

Spouse’s SSN__________________________

Spouse’s DOB____________________________________

Spouse’s Address___________________________________________________________________________

City, State, Zip________________________________________________

Phone____________________

Sponsor Address and Phone Changes. Date of change _________________________

New Sponsor Address_______________________________________________________________________

City, State, Zip_________________________________________ Phone__________________________

NOTE: To change your sponsor to another person, you will need to complete a Form 202 and mail to your caseworker or call 1-800-362-1504 to request a Form 202 be mailed to you.

Family Changes. Date of change _________________________

I Had a Baby. Baby’s Name is_______________________________________

Baby’s SSN_______________________________________

Male Female

Baby was Born on___________________(date) in ______________________________(city/state/zip)

Someone in My Household is Having a Baby. Her Name is______________________________

Date Baby is Due____________________ Number of Babies in Pregnancy__________________

Person(s) Moved Into My Home. Date of change _________________________

Name

Relationship

to You

Income

Date of

Birth

SSN

Receiving

SSI, Yes/No

Person(s) Moved Out of My Home. Date of change _________________________

Name

Relationship

to You

Income

Date of Birth

SSN

Form 295w (03/2009)

Alabama Medicaid Agency

Income Changes. Date of change __________________________

New Income.

Name

Employer Name

Gross Amount

Hourly

Hours

How

Day

 

and Address

of Pay (before

Pay

Worked

Often

Paid

 

 

deductions)

Rate

a Week

Paid

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Attach verification of income.)

Loss of Income. Person Who No Longer Has Income is__________________________________

Date of Last Pay Received_____________________.

Expense changes. Date of change ___________________________________

I Now Pay for Day/Night Care.

Name of Person Who Pays_______________________________________________________________

Name and Age of Person(s) in Care_______________________________________________________

Amount Paid______________________________ How Often________________________________

I No Longer Pay for Day/Night Care.

Insurance Changes. Complete the “Report Insurance Coverage Change Form” which is located on the Medicaid Website at www.medicaid.alabama.gov.

Report of Death.

Name of Recipient_________________________________ Date of death_________________________

I wish to close my Medicaid case. Date _________________________

Reason for closing case _____________________________________________________________________

I wish to withdraw my application. Date _________________________

Other Changes. Date of change_________________________

Explain__________________________________________________________________________________

__________________________________________________________________________________________

__________________________________________________________________________________________

By checking this box, I declare under penalty of perjury, that the information I have entered

is true and correct.

_____________________________________________________________

_______________________________

Signature of Recipient

 

 

Date

____________________________________________________________

______________________________

Person Helping to Fill Out Form

 

 

Daytime Phone Number

I am an Application Assister

Yes

No

 

You may E-mail this form by clicking on: changes@medicaid.alabama.gov.

How to Edit Form 295W Online for Free

Should you need to fill out Assister, there's no need to install any sort of applications - just use our PDF editor. To retain our editor on the leading edge of convenience, we strive to adopt user-oriented capabilities and improvements on a regular basis. We are at all times thankful for any feedback - join us in revolutionizing how we work with PDF docs. To begin your journey, consider these easy steps:

Step 1: Click the orange "Get Form" button above. It'll open our pdf editor so you can start filling out your form.

Step 2: This tool enables you to modify PDF forms in a variety of ways. Transform it by adding personalized text, adjust original content, and add a signature - all close at hand!

Completing this PDF demands attention to detail. Make certain all necessary blank fields are filled out properly.

1. Whenever completing the Assister, make certain to incorporate all of the essential blank fields within the associated part. It will help to hasten the work, allowing for your details to be processed promptly and correctly.

Step # 1 in filling out Alabama

2. Given that the previous array of fields is completed, you need to include the essential specifics in cid Sponsor Address and Phone, New Sponsor Address, City State Zip Phone, NOTE To change your sponsor to, mail to your caseworker or call, cid Family Changes Date of change, cid I Had a Baby Babys Name is cid, Babys SSN, Baby was Born ondate in, cid Someone in My Household is, Date Baby is Due Number of Babies, cid Persons Moved Into My Home, Name, Relationship, and Income so you can progress further.

Alabama completion process clarified (part 2)

Be really attentive when filling in cid Family Changes Date of change and Relationship, since this is the part in which most users make errors.

3. This subsequent segment is fairly straightforward, cid Persons Moved Out of My Home, Date of Birth, Relationship, Income, SSN, to You, Form w, and Alabama Medicaid Agency - each one of these blanks will have to be filled in here.

Form w, SSN, and Relationship of Alabama

4. This next section requires some additional information. Ensure you complete all the necessary fields - cid Income Changes Date of change, cid New Income, Name Employer Name, Gross Amount Hourly Hours, How, Day, and Address, of Pay before Pay Worked, Often Paid, deductions Rate a Week, Paid, Attach verification of income, cid Loss of Income Person Who No, Date of Last Pay Received, and cid Expense changes Date of change - to proceed further in your process!

Often Paid, Paid, and cid Loss of Income Person Who No inside Alabama

5. The form needs to be completed by filling in this area. Here you can find a detailed list of blanks that have to be completed with accurate details to allow your document usage to be faultless: cid Insurance Changes Complete the, located on the Medicaid Website at, cid Report of Death, Name of Recipient Date of death, cid I wish to close my Medicaid, Reason for closing case, cid I wish to withdraw my, cid Other Changes Date of change, Explain, cid By checking this box I declare, and is true and correct.

Filling out part 5 of Alabama

Step 3: Glance through all the details you've typed into the form fields and click the "Done" button. Grab your Assister the instant you register at FormsPal for a free trial. Conveniently view the pdf document from your personal cabinet, with any edits and changes being all synced! When using FormsPal, you can easily complete forms without the need to be concerned about database leaks or entries getting shared. Our protected software helps to ensure that your private data is maintained safe.