Downloading a Form to Your Computer
Fillable forms cannot be viewed on mobile or tablet devices. Follow the steps below to download and view the form on a desktop PC or Mac.
- Right Click for PC or Ctrl + Click for Mac on the PDF link and click “Save link as” from the menu.
- Select the folder you want to save the file in and then click "Save."
- Navigate to the folder you saved the file in and Right Click for PC or Ctrl + Click for Mac, then select "Open With" from the menu and select Adobe Acrobat Reader DC.
Note: Open the PDF file from your desktop or Adobe Acrobat Reader DC. Do not click on the downloaded file at the bottom of the browser since it will not open the PDF in Adobe Acrobat Reader DC. It will try to open the file in the browser that results in the same browser error message.
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- To remind individuals to send in the redetermination packet to continue health care benefit coverage for children under age 19.
- To explain the redetermination process and how to complete forms in the redetermination packet.
- To inform individuals that the Children’s Health Insurance Program (CHIP) coverage may be available if a child is no longer eligible for Medicaid.
When to Prepare
Send one copy of the form on the:
- first of the fifth month in a child's Medicaid six-month continuous eligibility period if the household did not return the redetermination packet in the fourth month.
- first of the 11th month in a child’s Medicaid 12-month continuous eligibility period if the household did not return the redetermination packet in the 10th month.
- first week of the 11th month in a child’s CHIP continuous eligibility period if the household did not return the redetermination packet in the 10th month.
Number of Copies and Transmittal
Mail one form to each applicant.
No retention requirements.
The form is self-explanatory.