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.

• 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.

• Patient Liability Change Report W-1696

  Patient Liability Change Report

• 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.