Applications and Forms
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Proof of Food Loss Form
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Therapeutic Diet Request W-351
Therapeutic Diet Request.
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W-300SA - Medical Report For SAGA Cash Benefits - Rev.12-19
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Request for Replacement SNAP Benefits - Spanish
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W-650 - Authorization for Reimbursement of Interim Assistance - Rev. 09/10
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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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Patient Liability Change Report W-1696
Patient Liability Change Report
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Determination of Spousal Assets W-1-SA
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.
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W-682 - DIRECT DEPOSIT AUTHORIZATION FORM - Rev. 1-23
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Determination of Spousal Assets W-1-SAS - Versión en Español
Aplicación para la Determinación de Bienes Personales del Esposo (de la Esposa)
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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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W-650S - Autorización para Reembolso de Asistencia Interina - 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