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.
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Patient Liability Change Report W-1696
Patient Liability Change Report
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W-0534FHS - Audiencia Imparcial - Rev. 05-23
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W-944 - Notice of Action - Rev. 05-23
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W-300MED - For Medicaid for the Employed Disabled - Rev. 12-19
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W-0534FH Fair Hearing Notice - Rev. 05-23
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W-650 - Authorization for Reimbursement of Interim Assistance - Rev. 09/10
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Client Rights and Responsibilities - W-0016RR Rev 1-23 - English
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Client Rights and Responsibilities - W-0016RRS Rev 1-23 - Spanish
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W-682 - DIRECT DEPOSIT AUTHORIZATION FORM - Rev. 1-23
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W-675 - Report Form For Protective Services For The Elderly - Rev. 06/23
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W-300SA - Medical Report For SAGA Cash Benefits - Rev.12-19
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W-650S - Autorización para Reembolso de Asistencia Interina - Rev. 09/10
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W-300T19 - Medical Report For Title XIX Disability Determination - Rev.12-19
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W-682S - FORMULARIO DE AUTORIZACIÓN DE DEPÓSITO DIRECTO - Rev. 1-23