Permission to Share LTC Insurance Information (DHS-5426A)
The Permission to Share Long-Term Care Insurance Information (DHS-5426A) (PDF) is a release of information sent to the client for signature. It allows the worker or DHS to communicate with the insurance company for up to one year. It was designed specifically to use when a client has LTC insurance.
Send the DHS-5426A in the following situations:
- Before sending the LTC insurance policy to HealthQuest. This will allow DHS to contact the insurance company to determine if it is a qualified Partnership policy and to determine what, if any, benefits have been used.
- At annual renewal if the LTC insurance benefits were not previously exhausted, and the previous release has expired.
Prior to sending the form to the client you must complete:
- The “What do I need to do?” section including the due date for return of the form. (10 working days).
- Client information on the second page.
To Do: Take a few minutes to review the form.
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LTCP Forms