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Eligibility Forms and Applications

   
Form Description
Joint Application NEW! Apply for coverage that starts on or after January 1, 2014
Appendix A Form to go with application if someone in the household is eligible for health coverage from a job
Appendix B Form to use if applicant or family member is an American Indian or Alaska Native
Appendix C Form to use if applicant wishes to give a trusted person permission to help with the application (authorized representative)
   
Joint Application (Spanish) Apply for coverage that starts on or after January 1, 2014
Appendix A (Spanish) Form to go with application if someone in the household is eligible for health coverage from a job
Appendix B (Spanish) Form to use if applicant or family member is an American Indian or Alaska Native
Appendix C (Spanish) Form to use if applicant wishes to give a trusted person permission to help with the application (authorized representative)
   
Apply Online Use online form for SOBRA, MLIF or Plan First
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.
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.
Form 211
Information
Addresses to mail application
Get more information
about the Medicare Savings Program
Form 357 Plan First Program application for family planning services
   
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 295 To tell Medicaid about changes to a recipient's status (move, income, marital status, etc.) - Fillable
295 Instructions Instructions for Form 295 Recipient Change Report