DSS: Applications and Forms

Applications and Forms



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 (Rev 7-16) (23KB)(MS Word)    

Versión en Español (Rev 7-16) 

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)   (130KB)

Programa De Cuidado En El Hogar Para Los Envejecientes De Connecticut Forma De Solicitud Para Cuidado En El Hogar (W-1487S)    (386KB)

Confidentiality and Non-disclosure Agreement for Contractor Employees (W-1077C) (MS Word)

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

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) 

Medicaid Prescription Voucher/Authorization for Payment (W-1069) (1781KB)   

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

Medicare Clearance Form (W-9) 

Medicare Savings Program Application (W-1QMB)  - Word

Formulario de Renovación de programas de ahorro de Medicare (W-1QMBS) - Word

Medicare Savings Programs Redetermination (W-1QMBR) - Word
      Re-determinación para los Programas de Ahorros de Medicare (W-1QMBRS)-Word  

W-265 Report of Admission or Discharge Rated Housing Facility/Residential Care Home (171KB)

W-300Med (New 1/16)  Medical Report - Medicaid for the Employed Disabled  - Word

W-300SA (New 1/16)  Medical Report - SAGA Cash Benefits - Word  

W-300T19 (New 1/16)  Medical Report - Title XIX Disability Determination  - Word

Permission to Share Medical Info (W-303A)    

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

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

Protective Services for the Elderly - Report Form W-675 

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)

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

SNAP ABAWD Work Requirement Medical Report (W-1210)


Content Last Modified on 7/7/2017 3:33:46 PM