DSS: Applications and Forms


Applications and Forms

 

The Department of Social Services provides a broad range of services to the elderly, people with disabilities, families, and individuals who need assistance in maintaining or achieving their full potential for self-direction, self-reliance and independent living.  In order to receive services from the Department of Social Services, you will need to apply.

 


 

General Application for food, cash and certain medical coverage:

 

Households and individuals who wish to apply for SNAP (Food Stamps), Medicaid for the Aged/Blind/Disabled (HUSKY C), Medicaid for Employees with Disabilities (MED-ConneCT), and/or cash assistance should use this (W-1E) application.

 

To apply on line, please visit www.connect.ct.gov, under ‘Apply for Benefits.’  

 

You can also download the ‘W-1E’ application for these programs:

Eligibility Determination Document (W-1E) with Instructions (6,258KB)

Versión en Español  

 


HUSKY A & B


Connecticut children and their parents or a relative caregiver; and pregnant women may be eligible for HUSKY A (Medicaid), depending on family income. 
 
Uninsured children under age 19 in higher-income households may be eligible for HUSKY B (also known as the Children’s Health Insurance Program).  Depending on specific income level, family cost-sharing applies.

 

To apply online, please visit www.connect.ct.gov, under ‘Apply for Benefits’ or ‘Get Health Insurance.’

 

To apply by phone for HUSKY A or B, please call the Access Health CT call center at 1-855-805-HEALTH (4325).

 


HUSKY D
Connecticut residents aged 19 up to 65th birthday, who do not qualify for HUSKY A; who do not receive Medicare; and who are not pregnant, may qualify for HUSKY D (also known as Medicaid for the Lowest-Income Populations). 

 

To apply online for HUSKY D, please visit www.connect.ct.gov, under ‘Apply for Benefits’ or ‘Get Health Insurance.’ 

 

To apply by phone, please call the Access Health CT call center at 1-855-805-HEALTH (4325).

 

**New Medicaid Long-Term Care Application Process at DSS**
 
To better serve our applicants, clients and providers, effective October 1, 2013, DSS has launched four Long-Term Care Application Centers.  The Centers will receive and process new applications from specific cities and towns for nursing home and Medicaid waiver home care applications.
 
The Long-Term Care Application Centers are located in the DSS Waterbury, Bridgeport, Hartford and New Haven field offices.  Please check this table for which Application Center to use, based on your city or town.
 
Application packets with as much documentation as possible should be mailed directly to the appropriate Long-Term Care Application Center. Please discontinue mailing new applications to the DSS ConneCT Scanning Center.  We cannot accept applications by fax because of the size and volume of most LTC applications.  (In the near future, we will begin accepting applications online; these will be electronically routed, based on the address of the applicant, to the appropriate Long-Term Care Application Center.  More information will be posted as it becomes available.)

Please note that these centers are processing new applications only.  Long-term care redeterminations and interim changes, as well as boarding home and residential care home applications and redeterminations, will continue to be processed through the statewide ConneCT model.  This means that all paperwork for redeterminations and interim changes, as well as boarding home applications and redeterminations, should be sent to the DSS ConneCT Scanning Center at P.O. Box 1320, Manchester CT 06045 (not to the new Long-Term Care Application Centers).
 
The Long-Term Care Application Centers also support admissions and discharges affecting area nursing homes in the ASCEND system.

For questions specific to a pending case, clients may call the assigned caseworker directly.  Applicants will be provided a worker’s contact information once the case is assigned.  For all other general calls or questions, the DSS Benefits Center staff will be happy to serve you at 1-855-6-CONNECT (1-855-626-6632).

Long-Term Medical Care / Home Care Application (W-1LTC)  (218KB)
 


Other Applications, in alphabetical order:
 
Acquired Brain Injury (ABI) Waiver Request Form (23KB)     

Versión en Español 

CADAP Application (345KB)  

CADAP Application (en Español) (367KB)  

Certificate for Disclosure of Gross Wages, Salary or Commission Paid (W-35)(MS Word)

Client Supplement for Medical Information (W-303  

(Version en Espanol)   

ConnPACE Application (English and Spanish versions)  {Internet Icon}  (link)

CT Home Care Program for Elders Home care Request Form(W-1487) (MS Word)

Programa De Cuidado En El Hogar Para Los Envejecientes De Connecticut Forma De Solicitud Para Cuidado En El Hogar (W-1487S) (113KB)

Elderly Services Medicine Record 

Department of Social Services Electronic Health Screen (141KB)

Determination of Spousal Assets  (W-1-SA)(623KB)

Aplicación para la Determinación de Bienes Personales del Esposo (de la Esposa) (W-1-SAS)(623KB)

Eligibility Redetermination Document (W-1ER) (1037 KB) 

Exception to Deeming for Needy Non-Citizens  (W-724)(MS Word)

HIPPA Authorization of Disclosure of Information (W-298) (PDF 84KB)

HIPPA Authorization of Disclosure of Information (Versión en Español) (W-298S) (PDF 87KB)

HUSKY Non-Custodial Parent Information Sheet (W-39) {Internet Icon}  (link)

Página HUSKY Información Acerca del Padre sin Custodia (W-39S)  {Internet Icon}  (link)

Mandated Reporter Form for Long Term Care Facilities (13KB) 

Medical Insurance Information (W-1685) (43KB) English & Spanish 

Medical Report (W-300 For Medicaid disability and SAGA cash benefits) 

Medical Statement (W-300A)    

Medicare Clearance Form (W-9) 

Medicare Savings Program Application/Redetermination (84KB) 

Medicare Savings Program Application/Redetermination (Versión en Español) (84KB) 

Permission to Share Medical Information (W-303A)    

Personal Care Assistance (PCA) Waiver Request Form (569KB)    

Personal Care Assistance (PCA) Waiver Request Form (Versión en Español)    

SAGA Application for Payment of Funeral and Burial Expenses (W-1053)  

Self-Employment Income Verification Form (W38) (MS Word)

Self-Employment Income Verification Form” (W38S) (Versión en Español) (MS Word)

Tenant Inspection (W-374 )     

(Version en Espanol)   

Therapeutic Diet Request (W-351)(MS Word)



Content Last Modified on 1/10/2014 2:41:33 PM