Hello my name is Janice welcome to this video tutorial on how to complete Medicaid renewal form d2 please carefully read page 1 if you have any questions about completing this form you can call eight five five five three two five four six five please be sure to respond by the date printed on the renewal form page two lists the ESA service centers you may visit any of the service centers to renew your Medicaid page three section one contains your contact information please verify and update any wrong or missing information if necessary please indicate if you would like to receive electronic notifications if so please provide your email address if your preferred spoken or written language is not English please tell us what language you prefer section two ask questions about who files federal tax returns section three contains individuals currently in your household please be sure to check the appropriate box for the question does this person still live with you if any individual listed in section three is deceased please write their name in this section in Section four list anybody else in your household or on your tax return be sure to fill out attachment a for anyone you've added in this section who wants to apply for Medicaid coverage in section 5 check the appropriate box to indicate if anyone you have added in section 4 who is applying for Medicaid coverage is an immigrant if you checked yes you must complete attachment D in addition to attachment a for each individual who is an immigrant in section 6 tell us about other health coverage you may have for anyone listed in sections 3 and 4 with Medicaid and anyone who is applying for health insurance coverage section seven asked various questions about the people listed on this renewal form who are renewing or applying for health coverage lists anyone who has a physical mental or emotional health condition that causes limitations in activities list anyone who is blind or terminally ill list anyone who has a child in the home who is 18 and a full-time student list anyone who is under age 26 and exited DC foster care at age 18 or older list anyone who is pregnant list anyone who is incarcerated check the box if anyone is an American Indian or Alaska native and fill out attachment B section eight contains information on wages and salaries from employment cross out any information that is not correct and write in any new information on the second page of section eight lists anyone in your household who has changed jobs or has worked fewer hours in the past four months is self-employed has deductions such as alimony paid to someone else student loan interest paid or other deductions section nine contains information on other sources of income cross out any information that is not correct and write in any new information Section ten contains the Privacy Act statement options for renewal of coverage and your rights and responsibilities please do not forget to sign and date this renewal form at the end...
