Applications and Forms
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Acquired Brain Injury (ABI) Waiver Request Form W-1130
Application for Acquired Brain Injury (ABI) Waiver Request.
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Acquired Brain Injury (ABI) Waiver Request Form W-1130S - Versión en Español
Application for Acquired Brain Injury (ABI) Waiver Request - Versión en Español.
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Application for Benefits (W-1ES) - Spanish
Application for Benefits (W-1ES) - Spanish
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To order bulk quantities of DSS forms, please follow this link to our Forms Requisition Site.
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Certificate for Disclosure of Gross Wages, Salary or Commission Paid W-35
Certificate for Disclosure of Gross Wages, Salary or Commission Paid
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CHCPE Request for Referral - Spanish W-1487S
CHCPE Request for Referral - Spanish
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CHCPE Request for Referral W-1487
CHCPE Request for Referral
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Client Supplement for Medical Information W-303
Client Supplement for Medical Information.
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Client Supplement for Medical Information W-303S - Versión en Español
Client Supplement for Medical Information - Versión en Español.
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Confidentiality and Non-disclosure Agreement for Contractor Employees W-1077C
Confidentiality and Non-disclosure Agreement for Contractor Employees.
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Department of Social Services Electronic Health Screen W-1506web
Department of Social Services Electronic Health Screen.
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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.
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Determination of Spousal Assets W-1-SAS - Versión en Español
Aplicación para la Determinación de Bienes Personales del Esposo (de la Esposa)
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Eligibility Re-determination Document W-1ER
Eligibility Re-determination Document