Eligibility Forms

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COVID-19: Get the latest updates on COVID-19 at ct.gov/coronavirus. Find a vaccination site near you at ct.gov/covidvaccine.

Forms

Checklist for Application (PDF 137 KB) Checklist for Application Spanish (PDF 225 KB)
Application(PDF, 1 MB) Application Spanish (PDF, 1 MB)
Acknowledgement Form for HIPAA (PDF, 26 KB)
Authorization for Release of Information(DOC, 195 KB)
Request for Hearing – Eligibility Services (PDF, 39 KB)