Form DHS-114A "Deductible Report" - Michigan

What Is Form DHS-114A?

This is a legal form that was released by the Michigan Department of Health and Human Services - a government authority operating within Michigan. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2007;
  • The latest edition provided by the Michigan Department of Health and Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form DHS-114A by clicking the link below or browse more documents and templates provided by the Michigan Department of Health and Human Services.

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Download Form DHS-114A "Deductible Report" - Michigan

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Case Name:
Case Number:
Date:
Specialist:
Phone:
Fax:
Email:
Department of Human Services (DHS) will not discriminate
against any individual or group because of race, religion, age,
ENTER ADDRESSEE NAME
national origin, color, height, weight, marital status, sex, sexual
ENTER ADDRESSEE CARE OF
orientation, gender identity or expression, political beliefs or
disability. If you need help with reading, writing, hearing, etc.,
ENTER ADDRESSEE PO BOX OR STREET
under the Americans with Disabilities Act, you are invited to
ENTER ADDRESSEE CITY/STATE/ZIP
make your needs known to a DHS office in your area.
DEDUCTIBLE REPORT
EACH TIME A MEDICAL EXPENSE IS INCURRED BY A MEMBER OF YOUR FAMILY, COMPLETE ONE LINE OF THIS FORM. GIVE
ALL REQUESTED INFORMATION. KEEP COPIES OF BILLS OR RECEIPTS FOR ALL MEDICAL EXPENSES, WE NEED TO SEE THEM.
PROVIDER NAME
DATE OF
CHECK
AMOUNT OF
TOTAL AMT
SERVICE
NAME OF FAMILY MEMBER
ONE
AND ADDRESS
CHARGE
TO DATE
Doctor Visit
Prescription
Other
Doctor Visit
Prescription
Other
Doctor Visit
Prescription
Other
Doctor Visit
Prescription
Other
Doctor Visit
Prescription
Other
Doctor Visit
Prescription
Other
Doctor Visit
Prescription
Other
Doctor Visit
Prescription
Other
Doctor Visit
Prescription
Other
Doctor Visit
Prescription
Other
Doctor Visit
Prescription
Other
When the expenses listed above are more than your deductible amount, return this form to your specialist immediately. You
may bring this form and proof of your medical expenses and income to the office or mail them in. COMPLETE,
SIGN AND DATE PAGE 2 OF THIS FORM BEFORE YOU RETURN IT.
1. List yourself and the name of each family member who lives with you.
DHS-114A (Rev. 12-07) MS Word
1
Case Name:
Case Number:
Date:
Specialist:
Phone:
Fax:
Email:
Department of Human Services (DHS) will not discriminate
against any individual or group because of race, religion, age,
ENTER ADDRESSEE NAME
national origin, color, height, weight, marital status, sex, sexual
ENTER ADDRESSEE CARE OF
orientation, gender identity or expression, political beliefs or
disability. If you need help with reading, writing, hearing, etc.,
ENTER ADDRESSEE PO BOX OR STREET
under the Americans with Disabilities Act, you are invited to
ENTER ADDRESSEE CITY/STATE/ZIP
make your needs known to a DHS office in your area.
DEDUCTIBLE REPORT
EACH TIME A MEDICAL EXPENSE IS INCURRED BY A MEMBER OF YOUR FAMILY, COMPLETE ONE LINE OF THIS FORM. GIVE
ALL REQUESTED INFORMATION. KEEP COPIES OF BILLS OR RECEIPTS FOR ALL MEDICAL EXPENSES, WE NEED TO SEE THEM.
PROVIDER NAME
DATE OF
CHECK
AMOUNT OF
TOTAL AMT
SERVICE
NAME OF FAMILY MEMBER
ONE
AND ADDRESS
CHARGE
TO DATE
Doctor Visit
Prescription
Other
Doctor Visit
Prescription
Other
Doctor Visit
Prescription
Other
Doctor Visit
Prescription
Other
Doctor Visit
Prescription
Other
Doctor Visit
Prescription
Other
Doctor Visit
Prescription
Other
Doctor Visit
Prescription
Other
Doctor Visit
Prescription
Other
Doctor Visit
Prescription
Other
Doctor Visit
Prescription
Other
When the expenses listed above are more than your deductible amount, return this form to your specialist immediately. You
may bring this form and proof of your medical expenses and income to the office or mail them in. COMPLETE,
SIGN AND DATE PAGE 2 OF THIS FORM BEFORE YOU RETURN IT.
1. List yourself and the name of each family member who lives with you.
DHS-114A (Rev. 12-07) MS Word
1
Case Name
Case Number
Specialist
2. Does any family member receive
3. Does any family member pay
Total Monthly
Total Monthly
Total Monthly
any income from employment or
support or guardianship expenses?
Earnings
Child Care for
Total Monthly
Guardianship
self-employment?
Yes
No
Before
Employment
Support Paid
Expenses
Yes
No
If yes, complete the following:
Deductions
Purposes
Paid
If yes, complete the following:
Person Working
Person Paying Support/Guardianship Exp
$
$
$
$
Person Working
Person Paying Support/Guardianship Exp
$
$
$
$
4. Other income you have. Include income of all family members.
5. Assets you have. Include assets of all family members.
Every item must be completed
Every item must be completed
MONTHLY
WHOSE
VALUE OF
OWNER
TYPE OF INCOME
TYPE OF ASSET
AMOUNT
INCOME
ASSET
OF ASSET
Cash on hand, in a safety
Yes
Yes
Social Security Benefits
$
$
deposit box or patient trust
(RSDI)
No
No
fund
Yes
Yes
Supplemental Security
Savings, Checking or
$
$
Income (SSI)
No
Credit Union Accounts
No
Yes
Yes
Retirement or Pension
Home, life estate, life
$
$
Benefits
lease
No
No
Yes
Yes
Real Estate (not your
$
$
Veterans Benefits
home)
No
No
Mortgage, land contract or
Yes
Yes
$
$
Disability Benefits
other notes payable to
No
No
household member
Yes
Yes
Savings bonds or money
$
$
Rental Income
market funds
No
No
Yes
Yes
$
$
Workers Compensation
Stock or mutual funds
No
No
IRA, KEOGH, 401K or
Yes
Yes
Child Support or
$
$
deferred compensation
Alimony
No
No
accounts
Yes
Yes
Unemployment
$
$
Trust Fund(s)
Compensation
No
No
Yes
Yes
$
$
Military Allotments
Life Insurance
No
No
Yes
Yes
Gambling Distributions
$
$
Annuity
(Casino profit sharing)
No
No
Cars, trucks, boats,
Yes
Yes
$
$
Other
motorcycles, other
No
No
vehicles
Yes
Tools & Equipment,
$
I CERTIFY THAT TO THE BEST OF MY KNOWLEDGE,
Livestock or Crops
No
ALL ANSWERS ON THIS FORM ARE TRUE AND
Yes
COMPLETE.
$
Funeral contracts
No
Yes
$
Signature
Date
Burial plot(s), casket, etc.
No
Certificates of Deposit
Yes
$
(C.D.) or savings
No
certificates
Yes
$
Signature
Date
Other
No
Yes
$
Other
No
Department of Human Services (DHS) will not discriminate against any individual or group because of race, religion, age, national origin, color, height,
weight, marital status, sex, sexual orientation, gender identity or expression, political beliefs or disability. If you need help with reading, writing, hearing,
etc., under the Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your area.
DHS-114A (Rev. 12-07) MS Word
2
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