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West Virginia Income Maintenance Manual Chapter 1

West Virginia Income Maintenance Manual Page 40 Chapter 1 Application/Redetermination Process

The DFA-QSQ-1 is used for QMB, SLIMB, and QI-1 applications only. No DFA-RR-1 is required. When Low Income Subsidy (LIS) files are received from the Social Security Administration (SSA), applicants who are not current Medicare Premium Assistance (MPA) clients are issued a DFA-QSQ-1 through the eligibility system. 1.3.5 OTHER PROGRAMS The table below lists the application forms used for other DOHS assistance programs. Program Application Form – Common

Application Form – Program-Specific AIDS Drug Assistance Program (ADAP) DFA-2 or DFA-SLA-1 with DFA-SLA-S1 to determine Medicaid eligibility. AND ADAP Application Breast and Cervical Cancer (BCC) Program WV PATH OR BCC Application DFA-BCC-1 Children with Special Health Care Needs (CSHCN) Not applicable. - CSHCN Program Application CSHCN-1 Emergency Assistance DFA-2 OR Emergency Assistance Application DFA-EA-1 Indigent Burial Program Not applicable. - Application for Indigent Burial Program DFA-BU-1 Affidavit of Responsible Relative DFA-BU-2 Low Income Energy Assistance Program (LIEAP) DFA-2 and DFA-LIEAP-1b Supplemental LIEAP Form WV PATH and DFA-LIEAP-1b OR LIEAP Application DFA-LIEAP-1 Supplemental LIEAP Form DFA- LIEAP-1b LIEAP Emergency Repair and Replacement Not applicable. - Application for Emergency Repair and Replacement DFA- LIEAP-ERR-1