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BAM 110 1 of 28 APPLICATION FILING AND REGISTRATION BPB 2025-003 1-1-2025

BRIDGES ADMINISTRATIVE MANUAL STATE OF MICHIGAN DEPARTMENT OF HEALTH & HUMAN SERVICES

DEPARTMENT POLICY

Request for Assistance Family Independence Program (FIP), Refugee Cash Assistance (RCA), State Disability Assistance (SDA), Child Development and Care (CDC), Medicaid (MA), Food Assistance (FAP) A request for assistance may be in person, by mail, telephone, email or online. The requester has the right to receive the appropriate application form: • MDHHS-1171, Assistance Application. The MDHHS-1171 packet includes an information booklet, the assistance application, and program specific supplement forms. A filing form used to preserve the application filing date for programs other than Medicaid, is available in the MDHHS-1171 and online at www.michigan.gov/dhs-forms. Note: A MI Bridges online application is considered the same as the MDHHS-1171. • DCH-1426, Application for Health Coverage & Help Paying Costs (all Medicaid categories). A Federal Facilitated Marketplace (FFM) application is acceptable for all Medicaid categories. • Brochures are available on the MDHHS website at www.michigan.gov/mdhhs. Select Doing Business with MDHHS, then Forms & Applications. MDHHS Brochures Available for Download is located in Quick Links in the right navigation. • DHS-4574, Medicaid Application for Nursing Facility Patients, Long Term Care residents only. • DHS-1514, State Emergency Relief Application. Note: Local offices must assist clients who need and request help to complete the application forms; see Bridges Administrative Manual (BAM) 115, Application Processing. Note: If a requestor submits a MDHHS-1171 program specific supplement form(s) without the MDHHS-1171, Assistance Application, treat this as a request for assistance.