Medicaid Forms/Applications Medicaid Manual Temporary Assistance for Needy Families (TANF) Foster Care & Adoption. unpaid medical bills and you meet eligibility requirements during this time period. to a Department of Social Services local office. date applied dcn #1 dcn #2. applicant full legal naMe (first, Middle, last) Maiden naMe (if any) HOMe address (HOuse nuMber, street Or rural rOute, pO bOx, HOMeless) city, state, zip cOde Mailing address (if different frOM HOMe address) city, state, zip cOde priMary. Client Supplement for Medical Information - Versión en Español. Department of Social Services Electronic Health Screen.  Field Offices and our telephone Benefits Center are closed on Wednesdays More about Apply in person at your county Division of Social Services (DSS) office. to allow our staff time to process applications, renewals and related work. An Agency of the Commonwealth of Virginia, Background Investigations - Adult Facilities, Supplemental Nutrition Assistance Program (SNAP), WIC, Food Bank & Other Nutritional Assistance, Temporary Assistance for Needy Families (TANF), Interstate Compact on Adoption & Medical Assistance (ICAMA), Interstate/Intercountry Placement of Children (ICPC), Education and Training Voucher (ETV) Program, Background Investigations - Children's Facilities, Child Care Assistance - Approved Subsidy Vendors, Child Care Assistance - Become a Subsidy Vendor, Child Care Assistance - Parents & Guardians, Early Head Start & Child Care Partnership Grant, Religiously Exempt Child Day Centers (RECDC), Unlicensed Child Day Programs Receiving Child Care Subsidy Assistance, Voluntarily Registered Family Day Homes (VRFDH), Search for a Children's Residential Facility, Substance Use Disorder Prevention and Recovery, Mandated Reporters - Training & Resources, Other Ways to Apply for Medical Assistance, 2020 Income Limits & LTC Spousal Impoverishment Standard Changes Eff.

The application must first be made for Medicaid eligibility. Acquired Brain Injury (ABI) Waiver Request Form W-1130. It could be because it is not supported, or that JavaScript is intentionally disabled. www.ct.gov/dss/fieldoffices for full
**The DSS Waterbury Field Office will be closed Thursday, November 5, and Friday, November 6, 2020.

If you are interested in eligibility for the It's easy to apply!

www.connect.ct.gov and www.ct.gov/dss/apply; It seems that JavaScript is not working in your browser. Individuals who receive Supplemental Security Income (SSI) are automatically eligible and do not need to apply. To order bulk quantities of DSS forms, please follow this link to our Forms Requisition Site. Client Supplement for Medical Information. For information about how to apply for the Medicaid program that best meets your needs, see the ways to apply for different programs below. **The Department of Social Services will be closed Wednesday, November 11, 2020, in observance of Veterans Day. An application may also be picked up and taken home to fill out for Children’s Medicaid or NCHC for Children. coverage may go back three months prior to the month the application is received in the Department of Social Services if you have Social Services. Please visit Client Supplement for Medical Information W-303S - Versión en Español. You may also contact Customers can access benefit and application information, at 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.
**Response time at our telephone Benefits Center, 01-18-2018, 2015 Income Limits & LTC Spousal Impoverishment Standard Changes Eff. appLICaTIoN foR mo hEaLThNET (mEdICaId) foR offICE uSE oNLY.

(1-855-626-6632), is currently longer than usual. You may apply by printing the application below and mailing, faxing, or delivering your application to a Department of Social Services local office.

The start date of medical coverage depends on the date the application is received by the Department of Social Services. 24/7 access options at information about services at Field Offices, including interviews by appointment **DSS Field Offices are now open every Monday, Tuesday, Thursday and Friday, Confidentiality and Non-disclosure Agreement for Contractor Employees. Application form for Long Term Care related programs.

There are three ways to apply (one application works for Medicaid and Health Choice).

Certificate for Disclosure of Gross Wages, Salary or Commission Paid W-35, Certificate for Disclosure of Gross Wages, Salary or Commission Paid, CHCPE Request for Referral - Spanish W-1487S, Client Supplement for Medical Information W-303. or our Client Information Line at 1-855-6-CONNECT (1-855-626-6632) . Thank you for your patience. You may also apply online by clicking on the link below. Home | State Home Page | Disclaimer | Nondiscrimination | Accessibility | Privacy Policy | Intranet | Contact Us **24/7 access: COVID-19 Information: Connecticut residents are urged to continue taking precautions to prevent the spread of COVID-19. prior three months, include proof of income from month(s) prior to the month the application was submitted to the Department of Application for Benefits (W-1ES) - Spanish. How do I apply for South Dakota Medicaid? www.ct.gov/dss/fieldoffices.

and Child Support services.

alternate pHOne nuMber.

Apply online at ePass. Get the facts at ct.gov/coronavirus. It's easy to apply! cell Home Work.

You may apply by printing the application below and mailing, faxing, or delivering your application 2016 CT.gov | Connecticut's Official State Website. Some of the features on CT.gov will not function properly with out javascript enabled.

01-22-2015, 2016 Income Limits & LTC Spousal Impoverishment Standard Changes Eff.

Confidentiality and Non-disclosure Agreement for Contractor Employees W-1077C. your nearest Department of Social Services office or call 1.800.305.3064 to request an application be sent to you. Application for Acquired Brain Injury (ABI) Waiver Request - Versión en Español. If you Households and individuals who are over 65 and older, blind or with disability and wish to apply for or renew Medicaid (HUSKY C) or Medicaid for Employees with Disabilities (MED-Connect) can apply online at www.connect.ct.gov, under ‘Apply for Benefits.’. Application form for CHIP, Pregnant Women programs and Low Income Families programs.

from 8 a.m. to 4 p.m. Acquired Brain Injury (ABI) Waiver Request Form W-1130S - Versión en Español. ** DSS Field Offices are now open every Monday, Tuesday, Thursday and Friday, from 8 a.m. to 4 p.m. Field Offices and our telephone Benefits Center are closed on Wednesdays to allow our staff time to process applications, renewals and related work. You can apply for Medicaid at any time. Determination of Spousal Assets W-1-SAS - Versión en Español, Aplicación para la Determinación de Bienes Personales del Esposo (de la Esposa), Eligibility Re-determination Document W-1ER, © In order to process your application as quickly as possible, please complete the application as thoroughly as possible. Application for Acquired Brain Injury (ABI) Waiver Request. An interview is completed at DSS.

need assistance completing an application contact a Department of Social Services office nearest you or call 1.800.305.3064. interview is not required to apply for South Dakota Medicaid, however you may request one. Department of Social Services Electronic Health Screen W-1506web. 01-25-2016, Affidavit of Identity for Medicaid Applicants/Recipients Residing in an Institution, Appendix D: ABD, LTC Application (Spanish), Appendix E: Medically Needy Spenddown (Spanish), Commonwealth of Virginia Voter Registration Agency Certification, Cover Virginia Additional Person Supplement, Cover Virginia Additional Person Supplement (Spanish), Cover Virginia Application for Health Coverage and Help Paying Costs, Cover Virginia Application for Health Coverage and Help Paying Costs (Spanish), Medicaid Funded Long-term Care Service Authorization, Parents & Caretakers of Dependent Children, Supplemental Security Income (SSI) Recipients, Adults Aged 65 or Older, Blind or Disabled (not receiving SSI), Children or Adults Who Need Long-term Care in a Facility/Home & Community-based Care (Waiver) Services, someone interested in Family Planning Services (Plan First). Adoption Children Available for Adoption Child Placing Agencies (CPA) - Licensed CPA - Search for a Licensed Facility Family Engagement Foster Care (FC) Fill out a paper application and mail to or drop it off at your county DSS office. 01-17-2020, 2018 Income Limits & LTC Spousal Impoverishment Standard Changes Eff.

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