Get Bhsf Form 1-bcc Rev - Coverageforall

Filling out the BHSF Form 1-BCC Rev - Coverageforall is an essential step for individuals seeking to apply for Medicaid benefits through Louisiana’s Breast and Cervical Cancer Program. This guide offers clear, step-by-step instructions to help you complete the form online with ease.

Follow the steps to complete your application efficiently.

1. Click the ‘Get Form’ button to obtain the form and open it in the online editor.
2. Provide accurate personal information in the required fields, including your name, date of birth, and Social Security Number. You will also need to indicate your Hispanic or Latino status, race, U.S. citizenship status, and Louisiana residency.
3. Fill out your mailing and home addresses, including the city, state, and zip code for each. Ensure you provide a valid home phone number, other phone number, cell phone number, and your preferred contact time.
4. Indicate your language proficiency, both spoken and written, by selecting the appropriate options.
5. Answer the questions regarding your proof of screening for the Early Detection Program and indicate if you have private health insurance. If you do, provide the name, address, and phone number of the insurance company, as well as your group or policy number.
6. Provide information about any dependents under 18 living in your home and confirm if you are pregnant or have a disability.
7. Disclose your income sources, if applicable, and provide estimates of any expected due dates if pertinent.
8. Review the rights and responsibilities section carefully and ensure that all statements are true and correct. Prepare to sign the application, and if required, a representative's signature.
9. Once all fields are completed, save the changes, then download, print, or share the form as necessary before submitting it to your local Medicaid office.

Start your application process online and ensure you secure the benefits you need.