Get Fl Dh-3212 2006

Filling out the FL DH-3212 form online is an essential step in applying for the health insurance application for extended family planning benefits. This guide will provide you with clear, step-by-step instructions to ensure you complete the form accurately and efficiently.

Follow the steps to fill out the FL DH-3212 form online.

1. Click the ‘Get Form’ button to obtain the FL DH-3212 and open it in your editing platform.
2. Begin by entering your name, residence, and mailing address in the appropriate fields. Make sure to use your full name and accurate addresses, as this information is crucial for communication regarding your application.
3. Complete the section requesting your social security number, date of birth, race, sex, and proof of citizenship as necessary. Ensure that only the applicant provides this information.
4. Answer the reproductive history questions (1-3) by selecting 'Yes' or 'No' as applicable. Provide the date of your last menstrual period if applicable.
5. List all individuals living in your home, starting with yourself. Include their names, relationship to you, and relevant phone numbers.
6. Provide detailed information regarding income sources for yourself and all household members. This includes providing names, income sources, gross income amounts, and how frequently each amount is received.
7. Indicate whether you or anyone in your household has health insurance by selecting 'Yes' or 'No.' If 'Yes,' write the name of the insurance company.
8. Attach proof of U.S. citizenship and identity to your application. Ensure to only use original documents or certified copies.
9. Read the Certification and Authorization section carefully. Once you understand the agreement, sign and date the form.
10. Finally, after ensuring that all fields are accurately filled, you can save changes, download, print, or share the completed FL DH-3212 form.

Complete your FL DH-3212 application online today to secure your family planning benefits.