Applications and Forms

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• Acquired Brain Injury (ABI) Waiver Request Form W-1130

  Application for Acquired Brain Injury (ABI) Waiver Request.

• Acquired Brain Injury (ABI) Waiver Request Form W-1130S - Versión en Español

  Application for Acquired Brain Injury (ABI) Waiver Request - Versión en Español.

• Application for Benefits (W-1E) - English

  Application for Benefits (W-1E) - English - Latest Version

• Application for Benefits (W-1ES) - Spanish

  Application for Benefits (W-1ES) - Spanish - Latest Version

• Bulk Ordering of Forms

  To order bulk quantities of DSS forms, please follow this link to our Forms Requisition Site.

• CHCPE Request for Referral - Spanish W-1487S

  CHCPE Request for Referral - Spanish

• CHCPE Request for Referral W-1487

  CHCPE Request for Referral

• Determination of Spousal Assets W-1-SA

  This form is for use by individuals requesting an assessment of spousal assets when one spouse starts a continuous period of institutionalization of 30 or more days in a medical institution, long term care facility, or begins receiving home and community based services.

• Determination of Spousal Assets W-1-SAS - Versión en Español

  Aplicación para la Determinación de Bienes Personales del Esposo (de la Esposa)

• HIPAA Authorization for Disclosure of Information W-298

  HIPAA Authorization for Disclosure of Information W-298

• HIPAA Authorization for Disclosure of Information W-298S

  HIPAA Authorization for Disclosure of Information W-298S

• Inter-Agency Patient Referral Form W-10

  Inter-Agency Patient Referral Form Rev 02/23

• Medicare Clearance Form W-9

  Medicare Clearance Form.

• Medicare Savings Program Application W-1QMB

  Medicare Savings Program Application.

• Medicare Savings Program Application W-1QMBS - Versión en Español

  Formulario de Renovación de programas de ahorro de Medicare - Versión en Español.