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 download the ‘W-1E’ application for these programs:

Eligibility Determination Document (W-1E) with Instructions (6,258KB) - 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         

 


 
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)

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

HIPPA 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)

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 2/20/2015 3:33:09 PM