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Eligibility Forms and Applications
   
Form Description
Apply Online Use online form for SOBRA, MLIF or Plan First
AVAS
Apply Online		 Hear and see instructions for each step of the application process
Form 202 To appoint someone as a Medicaid recipient's representative
Form 204/205  
fillable		 Elderly & Disabled Application/Redetermination form - for someone in a hospital, nursing home or ICF/MR.  You may type information into this fillable form, print and mail or print the form and fill in by hand. Application CANNOT be faxed to Medicaid.
Form 204/205
Information		 Addresses to mail application 
 Get more information about applying for institutional Medicaid
Tips for applying
   
Form 211 - fillable Medicare Savings Program - Form for help paying Medicare premiums. You may type information into this fillable form, print and mail or print the form and fill in by hand. Application CANNOT be faxed to Medicaid.
Form 211
Information		 Addresses to mail application
Get more information about the Medicare Savings Program
   
Form 234 - fillable To notify Medicaid of important information relating to a claimant - fillable
234 Instructions Statement of Claimant - Instructions
Form 262 Form for a Medicaid applicant who is entering a nursing home and has excess income - Qualifying Income Trust Packet
Form 265 To request infant/child's Medicaid Number (providers only)
Form 284 To enroll children of Medicaid-eligible mothers (including SSI mothers) from birth to first birthday
Form 291 SOBRA Application for pregnant women, families and children under age 19 in English
Get more information about the eligibility requirements
Documents Needed to Apply
Form 291S SOBRA Application for pregnant women, families and children under age 19 in Spanish  
Form 291 Application for birth control and family planning services for women age 19-55 who have children under age 19
 Get more information
Documents Needed to Apply
 Form 295 - fillable To notify Medicaid of changes to a recipient's status (move, income, marital status, etc.) - Fillable
295 Instructions Instructions for Form 295 Recipient Change Report
Form 357 Plan First Application for birth control and family planning services for women ages 19-55 who have no children
Get more information about the Plan First Program
 Documents Needed to Apply