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Form 870 Birmingham Alabama: What You Should Know

Child Care Information Form or Form 2866 (PDF) Dental Plan Form 2866 (PDF) Medical Coverage and Expense Information Form — If the adult applicant was not named on a health care plan on which the applicant claims benefits, the form is required. Other Expenses Form 2866 (PDF) All Forms must be signed by an adult named in the form or a person who is an official representative of the adult. If the person signed the forms is an adult and is not named on a health care plan on which the adult claims benefit the form will not be considered complete. If you are applying for Medicaid or other program(IES) for which you do not qualify for health insurance you can fill out the form for all costs, but in these case you can contact the office first to verify that you qualify. Form 468-E. The form must be signed or stamped by a person who is named on the form. If you are a UHF resident you need to complete and sign form 468-E, Authorization for Release of Information (PDF) If your household income is below 133% GPL you may be eligible for Medicaid or other program(IES). The requirements for obtaining a determination that you do fall under the income eligibility requirements are stated below, for all states except for Indiana which has its own set of forms available from the Indiana State Health Benefits Program. Check your child's health plan carefully to see if he/she is enrolled in a plan that qualifies. If so, you need to check your state health benefit program to see if you qualify for a benefit. A state-by-state listing of approved plans can be found at: (accessed November 17, 2010, For Indiana, visit or call. Form 468-E (PDF) If you received a Form 468 and have not received a determination letter, but you suspect the information listed in the form is correct, and you do qualify for Medicaid and child health benefits, write a letter.  To get a letter request the form online at: and print it. This will be completed and provided to you in a sealed envelope.

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