Applications and Forms

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• 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.

• W-0534FHS

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

• W-944

  W-944 - Notice of Action - Rev. 05-23

• W-300MED

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

• W-0534FH

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

• W-650

  W-650 - Authorization for Reimbursement of Interim Assistance - Rev. 09/10

• 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-682

  W-682 - DIRECT DEPOSIT AUTHORIZATION FORM - Rev. 1-23

• W-675

  W-675 - Report Form For Protective Services For The Elderly - Rev. 06/23

• W-300SA

  W-300SA - Medical Report For SAGA Cash Benefits - Rev.12-19

• Patient Liability Change Report W-1696

  Patient Liability Change Report

• W-300T19

  W-300T19 - Medical Report For Title XIX Disability Determination - Rev.12-19

• W-650S

  W-650S - Autorización para Reembolso de Asistencia Interina - Rev. 09/10

• W-682S

  W-682S - FORMULARIO DE AUTORIZACIÓN DE DEPÓSITO DIRECTO - Rev. 1-23