Applications and Forms

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• Acquired Brain Injury (ABI) Waiver Request Form W-1130

  Application for Acquired Brain Injury (ABI) Waiver Request.

• Acquired Brain Injury (ABI) Waiver Request Form W-1130S - Versión en Español

  Application for Acquired Brain Injury (ABI) Waiver Request - Versión en Español.

• Application for Benefits W-1E

  To apply for long term care (nursing home) or home based care, apply online at connect.ct.gov, or in person at a DSS office, or using form W-1LTC. Call 855-626-6632 to ask for a W-1LTC form, or get form W-1LTC at a DSS office.

• Application for Benefits W-1ES - Solicitud de Beneficios

  Para solicite cuido a largo plazo (hogar de ancianos) o cuido en su hogar en línea en connect.ct.gov, o visite en persona una oficina del DSS, o use el formulario W-1LTC. Llame al 855-626-6632 para solicitar un formulario W-1LTC, u obténgalo en alguna oficina del DSS.

• Certificate for Disclosure of Gross Wages, Salary or Commission Paid W-35

  Certificate for Disclosure of Gross Wages, Salary or Commission Paid

• CHCPE Request for Referral - Spanish W-1487S

  CHCPE Request for Referral - Spanish

• CHCPE Request for Referral W-1487

  CHCPE Request for Referral

• Client Supplement for Medical Information W-303

  Client Supplement for Medical Information.

• Client Supplement for Medical Information W-303S - Versión en Español

  Client Supplement for Medical Information - Versión en Español.

• Confidentiality and Non-disclosure Agreement for Contractor Employees W-1077C

  Confidentiality and Non-disclosure Agreement for Contractor Employees.

• Department of Social Services Electronic Health Screen W-1506web

  Department of Social Services Electronic Health Screen.

• Determination of Spousal Assets W-1-SA

  This form is for use by individuals requesting an assessment of spousal assets when one spouse starts a continuous period of institutionalization of 30 or more days in a medical institution, long term care facility, or begins receiving home and community based services.

• Determination of Spousal Assets W-1-SAS - Versión en Español

  Aplicación para la Determinación de Bienes Personales del Esposo (de la Esposa)

• Eligibility Re-determination Document W-1ER

  Eligibility Re-determination Document

• Eligibility Re-determination Document W-1ERS - Versión en Español

  Eligibility Re-determination Document - Versión en Español.