Forms & publications

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Application for aged, blind, disabled/long-term care coverage

18-005

Application for health care coverage for individuals seeking aged, blind, disabled coverage or long-term services and supports.

Form
Order Form

Application for Apple Health (Medicaid) health care coverage

18-001P

Application for Modified Adjusted Gross Income Apple Health coverage and Qualified Health and Qualified Dental plans. (HCA 18-001P)

Form
Order Form

Application for Family Planning Only services (formerly Take Charge)

13-781

Application for Take Charge (family planning) services.

Form

Application for Medicare Savings Program

13-691

Application for the Medicare Savings Program, which may pay your Medicare premiums, copays and deductibles.

Form

Application for pregnant teen health care coverage (for teens under age 19)

14-430

Application for pregnant teen health care coverage for teens under the age of 19.

Form

Application for Tailored Supports for Older Adults (TSOA) program

18-008

Application for the Tailored Supports for Older Adults (TSOA) program which provides support for caregivers who are caring for a family member for free and those who do not have a family member to help them.

Form
Order Form

area-representatives.pdf

Shares the Health Care Authority Apple Health Area Representative (broken out by county) available to assist with questions about eligibility and policy for Apple Health (Medicaid) programs.

Publication

Assisters for Apple Health

19-000

List of assisters available to help individuals applying for or renewing Apple Health (Medicaid) coverage in Washington Healthplanfinder.

Publication

Authorization for release of information

80-020

Use this form to allow the Health Care Authority to release information or records.

Form

Authorized representatives

Webinar about authorized representatives and how the process works for Apple Health (Medicaid).

Publication

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