Applications and Forms

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• Patient Liability Change Report W-1696

  Patient Liability Change Report

• Report of Admission or Discharge Rated Housing Facility/Residential Care Home W-265

  Form W-265 is used by the Rated Housing Facility/Residential Care Home to notify the Department (1) when an individual is admitted to the home or facility, (2) when an individual is discharged from the home or facility (regardless of whether the discharge is temporary or permanent) and (3) when there is a change in discharge status from temporary to permanent.

• SAGA Application for Payment of Funeral and Burial Expenses W-1053

  SAGA Application for Payment of Funeral and Burial Expenses.

• SNAP ABAWD Work Requirement Medical Report W-1210

  SNAP ABAWD Work Requirement Medical Report.

• Therapeutic Diet Request W-351

  Therapeutic Diet Request.

• Vendor Direct Deposit Form W-260

  Vendor Direct Deposit Form

• W-0016RR

  Client Rights and Responsibilities - W-0016RR Rev 1-23 - English

• W-0016RRS

  Client Rights and Responsibilities - W-0016RRS Rev 1-23 - Spanish

• W-0534FH

  W-0534FH Fair Hearing Notice - Rev. 05-23

• W-0534FHS

  W-0534FHS - Audiencia Imparcial - Rev. 05-23

• W-1225

  Request for Replacement SNAP Benefits

• W-1225S

  Request for Replacement SNAP Benefits - Spanish

• W-1226

  Proof of Food Loss Form

• W-1226S

  Proof of Food Loss Form - Spanish

• W-300MED

  W-300MED - For Medicaid for the Employed Disabled - Rev. 12-19