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Forms for Recipients

Forms Number and Descriptions
Apply Online Use Online form for SOBRA, MLIF or Plan First
Joint Application Apply for coverage that starts on or after January 1, 2014
Appendix A if someone in the household is eligible for health coverage from a job
Appendix B if applicant or family member is an American Indian or Alaska Native
Appendix C Form to use if applicant wishes to give a trusted person permission to help with the application (authorized representative)
Medicaid Applications  
Form 204/205- fillable Application for Elderly and Disabled programs
Addresses to mail application - Updated 8/27/14
Tips for Applying Know what information you need to have when applying for elderly and disabled assistance  
Form 284 To enroll children of Medicaid-eligible mothers (including SSI mothers) from birth to first birthday
Eligibility Forms  
Form 202 To appoint someone as a Medicaid recipient's representative
Form 262 Qualifying Income Trust Packet- For a Medicaid applicant who is entering a nursing home and has excess income
Form 295 Recipient Change Form to tell Medicaid about changes to a recipient's status (move, income, marital status, etc.) - Fillable
Form 211 - fillable Medicare Savings Program Form for help paying Medicare premiums.
Form 211 Information Addresses to mail application - Updated 8/27/14
Get more information
about the Medicare Savings Program
Form 357 Plan First Application - for family planning services only
Third Party Benefit Coordination Forms  
Form 3P-1 Request Release of recipient's information - Fillable
Form 3P-2 To report changes in insurance coverage - Fillable
HIPP Application Health Insurance Premium Payment Application to mail or fax
Medical Authorization Form Authorization for release of information
Patient 1st Forms  
Form 354 Request for Newborn Assignment - Fax or Mail
Form 393 Grievance Form - to tell Medicaid if you have a complaint about a Patient 1st provider
Form 349  To change your personal doctor - fillable - Mail
Form 349 To change your personal doctor - fillable - Fax