Application for Assistance W-1F (4780KB)   

Note: One or two person households who wish to apply for cash assistance, medical assistance (including help paying for a nursing home) or food stamps should use this application.  You should print this application, complete it and return it to your local DSS office as soon as possible even if you do not have all of the required information.  This application cannot be submitted electronically.  Please consult the pamphlet Long Term Care Issues & Medicaid for a complete description of the eligibility requirements for nursing home assistance.

Acquired Brain Injury (ABI) Waiver Request Form (23KB)     

CADAP Application (345KB)  

Client Supplement for Medical Information (W-303 )   

ConnPACE Application (English and Spanish versions)   (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 Determination Document (W-1E) with Instructions (6,258KB) 

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

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

HIPAA  Authorization of Disclosure of Information (W-298) (MS Word)

HUSKY Application  

HUSKY Non-Custodial Parent Information Sheet (W-39)  (link)

Página HUSKY Información Acerca del Padre sin Custodia (W-39S)   (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)    

SNAP - Application for SNAP Only (133KB) 

Tenant Inspection (W-374 )     

(Version en Espanol)   

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