Applications and Forms

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

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

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

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

• 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

• W-1225

  Request for Replacement SNAP Benefits

• W-1226

  Proof of Food Loss Form

• W-1225S

  Request for Replacement SNAP Benefits - Spanish

• W-1226S

  Proof of Food Loss Form - Spanish

• QUESTIONS & ANSWERS: APPLYING FOR MEDICAID TO PAY FOR LONG TERM SERVICES AND SUPPORTS IN A NURSING FACILITY OR YOUR HOME

  Medicaid rules are complicated and change often. This information describes some of the rules for applying for Medicaid for Long-Term Care or Home Care. The complete rules are in the Department of Social Services Uniform Policy Manual.

• PREGUNTAS Y RESPUESTAS SOBRE CÓMO SOLICITAR MEDICAID PARA PAGAR SERVICIOS Y APOYOS A LARGO PLAZO EN UNA RESIDENCIA PARA ANCIANOS O EN SU HOGAR

  Las reglas del Medicaid son complicadas y pueden cambiar con frecuencia. Esta información describe algunas de las normas referentes a la solicitud para cuidados a largo plazo o cuidados a domicilio.

• Therapeutic Diet Request W-351

  Therapeutic Diet Request.

• Medicare Clearance Form W-9

  Medicare Clearance Form.

• CHCPE Request for Referral W-1487

  CHCPE Request for Referral

• Request for Exemption from the SNAP Time Limit (W1460) - English

  Request for Exemption from the SNAP Time Limit (W-1460) - English - Rev. 10/24

• Request for Exemption from the SNAP Time Limit (W1460S) - Spanish

  Request for Exemption from the SNAP Time Limit (W-1460S) - Spanish - Rev. 10/24