Publications

Page 5 of 11

• 16-07

• 17-01

• 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

• Children Health Insurance Program (CHIP) State Plan Amendment

  HUSKY B is Connecticut’s Children’s Health Insurance Program (CHIP, also known as Title XXI). HUSKY B provides a free or low cost health insurance program for children and youth up to age 19 for families who are not income eligible for HUSKY A.

• 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.

• Community First Choice program: Q&A for Applicants and Family Members from Departments of Social Services and Developmental Services

  Community First Choice is a program that provides personal care attendant services to people with disabilities living in the community.

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

  Confidentiality and Non-disclosure Agreement for Contractor Employees.

• Connecticut Plans for the federal Low-Income Home Energy Assistance Program and Community Services Block Grant for Federal Fiscal Year 2020