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Medical Services - Appendix I, Application Form Chart Appendix I (01/23) Page 2 of 2 Eligibility Group Waivers TEFRA X * * X X X ● ● ● X Autism X * * X X ● ● ● Miscellaneous Workers with Disabilities X * * X ● ● ● Aged Individual-EC X * * X Aged Individual-SD X * * X AFDC-EC X * * * X ● ● ● AFDC-SD X * * * X ● ● ● Blind Individual-EC X * * * X ● ● ● Blind Individual-SD X * * * X ● ● ● Disabled Individual-EC X * * * X ● ● ● Disabled Individual-SD X * * * X ● ● ● Under 18 Years of Age-SD X * * * X Pregnant Woman-EC X * * X Pregnant Woman-SD X * * X AFDC-UP-EC X * * X AFDC-UP-SD X * * X Refugee Resettlement-EC X * * X ● ● ● Refugee Resettlement -SD X * * X ● ● ● Foster Care-EC X * * * X Foster Care-SD X * * * X Former SSI Medicaid Categories Must have been an SSI Recipient Pickle (COLA) X * * X Disabled Adult Child (DAC) X * * X Widows or Widowers (OBRA 90) X * * X A green X signifies this form will be needed for an application. A red dot ● signifies this form will be needed for an application if a disability determination from MRT is needed. A blue asterisk * signifies this form may be needed, depending on the circumstances. (e.g. DCO-0090 when there is an absent parent)