Applications and Forms
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Acquired Brain Injury (ABI) Waiver Request Form W-1130S - Versión en Español
Application for Acquired Brain Injury (ABI) Waiver Request - Versión en Español.
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Inter-Agency Patient Referral Form W-10
Inter-Agency Patient Referral Form Rev 02/23
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Client Rights and Responsibilities - W-0016RRS Rev 1-23 - Spanish
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Client Rights and Responsibilities - W-0016RR Rev 1-23 - English
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W-650 - Authorization for Reimbursement of Interim Assistance - Rev. 09/10
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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.
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W-300MED - For Medicaid for the Employed Disabled - Rev. 12-19
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Medicare Savings Program Application W-1QMBS - Versión en Español
Formulario de Renovación de programas de ahorro de Medicare - Versión en Español.
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Medicare Savings Program Application W-1QMB
Medicare Savings Program Application.
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Vendor Direct Deposit Form W-260
Vendor Direct Deposit Form
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W-300T19 - Medical Report For Title XIX Disability Determination - Rev.12-19
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W-944 - Notice of Action - Rev. 05-23
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Proof of Food Loss Form - Spanish
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Request for Replacement SNAP Benefits
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W-682 - DIRECT DEPOSIT AUTHORIZATION FORM - Rev. 1-23