Applications

• To apply for cash, Food Stamp benefits, Medicaid, and Child Care assistance, complete both:
  • Application for Assistance (Form 800)
    • Solicitud de Asistencia (Spanish)
  • Medical Assistance for Children, Pregnant Women, & Parent/Caretaker Relatives Insert (Form 800 Insert)
    • Asistencia Médica para niños, mujeres embarazadas, y del padre / parientes a cargo de inserción (Spanish)
• Authorized Representative (Form 778)
  • Representante Autorizado (Spanish)
• Application for Health Coverage and Help Paying Costs (Form 800MA)
  • La solicitud de cobertura de salud y los costos de pago Ayuda (Spanish)
• Your Rights & Responsibilities (Form 811R)
  • Sus Derechos y Responsabilidades (Spanish)

Verifications

• Authorization for Release of Protected Health Information (Form 752A)
  • Autorización para la divulgación de la información médica protegida (Spanish)
• Eligibility Verifications (Form 800V)
  • Las verificaciones de elegibilidad (Spanish)
• Employment Verification (Form 756)
• Non-Medical Evaluation of Disability-DDU (Form 177)
• Physician/Clinician Statement of Capabilities (Form 752)
• Physician/Clinician Statement of Necessary Patient Care (Form 752HH)
• Rental Verification (Form 775)
• Shared Shelter Arrangements (Form 768)
  • Arreglos refugio compartidos (Spanish)
• Certification of Continued Absence (Form 773)
  • Certificación de ausencia Continuación (Spanish)
• Determination of Incapacity Status (Form 720)
  • Determinación de Incapacidad Estado (Spanish)
• Attestation and Verification of Food Stamp (FS) Household Disaster (Form 474)
  • Certificación y verificación de Cupones para Alimentos (FS) Desastres Domésticos (Spanish)

Additional Information

• Family Assistance Fact Sheet (effective March 1, 2020)
• Income Limits by Program (effective March 1, 2020)
• Instructions for Physician/Clinician Statement of Capabilities, Physician/Clinician Statement of Necessary Patient Care and Authorization for Release of Protected Health Information

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