Forms used in the application process

Official source

The application process begins and the application date is established when the request for benefits is received. These are the forms used in the application process for LTSS.

HCA forms , including translations are found on the HCA forms website.

DSHS forms , including translations are found on the DSHS forms website.

HCA 18-003 - Rights and responsibilities (translations can be found at Health Care Authority (HCA) forms under 14-113 )

HCA 18-005 - Washington Apple Health application for aged, blind, disabled/long-term care coverage

HCA 18-008 - Washington Apple Health application for tailored supports for older adults (TSOA)

DSHS 14-00 - Application for cash or food assistance1 (used for any cash, food, or medical care services [MCS] request as MCS is tied to ABD cash/HEN eligibility)

HCA 14-194 - Medical coverage information (used to report third party insurance coverage including LTC insurance)

DSHS 14-539 - Revocable burial fund provision for SSI-related health care

DSHS 14-540 - Irrevocable burial fund provision for SSI-related health care

DSHS 14-454 - Estate recovery fact sheet (repaying the state for medical and long-term services and supports)

DSHS 14-501 - Community resource declaration (used to evaluate resources [assets] for an applicant and their spouse based on date of institutionalization under WAC 182-513-1350 )

DSHS 14-532 - Authorized representative release of information .

DSHS 10-438 - Long-term care partnership (LTCP) asset designation form (used to designate assets [resources] for those with a long-term care partnership insurance policy)

DSHS 14-012 - Consent (release of information form) (used for all DSHS programs)

DSHS 27-189 - Asset Verification Authorization

HCA release of information and DSHS consent forms

The HCA 80-020 - Authorization for Release of Information is for medical benefits under the Health Care Authority (HCA) and will be accepted as a release of information for all medical programs including LTSS programs. The DSHS consent form is preferred as it is used for all programs including medical, food, and cash.