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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.
To notify the client/authorized representative of the opportunity to claim a hardship for Medicaid Buy-In for Children (MBIC) benefits due to a qualifying change in the client or client's household life.
When to Prepare
The system sends Form H0065-MBIC when it sends Form H0062-MBIC, Late Payment Notice.
Number of Copies
The system prepares one copy.
The form is sent to the client at the client's address or that of the authorized representative. A prepaid return envelope is enclosed.
The system retains a copy for the electronic case record.
This form is pre-populated by the system. If the form is completed manually, follow these instructions.
MBIC EDG number — Enter the MBIC eligibility determination group (EDG) number for each eligible child.
Case number — Enter the case number in the system.
Due date — Enter the date 10 days from date of this letter.
Client name and address — Enter the client's name and the address including city, state and ZIP code.
Answer these 4 questions — The client/authorized representative must answer yes or no for all four questions.
Signature, Date and Phone Number — The client/authorized representative must sign and date the form, and provide a phone number (or telephone number of a contact) for the form to be complete.