DSS: Applications and Forms


Applications and Forms


 

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 use the ‘W-1E’ form to apply for these programs, available here. - Versión en Español

 

For HUSKY Health (Medicaid & Children’s Health Program), please follow this link.  

 

For Medicaid Long-Term Services and Supports (including home- and community-based care and nursing home care), please follow this link         


 

Verification for Programs

 

We may ask you to give us proof of some of the information that you tell us. Visit this link for a full guide to verifications required for DSS programs. This list gives you examples of some of the types of proof that you can use when applying for programs. If we ask you for proof and you do not have one of the items in this list, please call the DSS Client Information Line and Benefits Center at 1-855-6-CONNECT. A Benefits Center representative will be able to tell you about other types of proof that we can use. Guide to Verification for Programs (Versión en Español)

 


 
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)   

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)    Versión en Español

Client Rights and Responsibilities (W-0016RR)   Versión en Español

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

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

HIPAA 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)

HUSKY Presumptive Eligibility Application (W-1PE) (979KB) 

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 5/7/2015 8:08:54 AM