Forms & Applications

Consumer Applications

• To apply for health and human services see the consumer section of this website.  Individuals and families can apply online, mail in a completed paper application or apply by phone. When applying for any program, accompanying documents are usually required. 
• For information on Katie Becket and how to apply, see Katie Beckett.
• For information on Medicaid Long-Term Services and Supports (LTSS), see Medicaid LTSS.
• Application for State Assistance to Pay for Healthcare Coverage

Forms

  Access to Public Records Requests (APRA):

• APRA Information & Guidelines
• APRA Request Form

Changes to Medicaid LTSS:

• LTSS Change Report Form

Home Care Information:

• Home Care Services Request Form and Instructions
  
  (for former RHO Unity members)
• Electronic Visit Verification (EVV) Info
  
  (for former RHO Unity members)

Long Term Care Forms:

• Referral for Preventive or Medically Complex Needs (GW-OCP)
• Request for Level of Care/Cover Sheet (GW-RR)  
• Medical Evaluation of Applicant for Level of Care (GW_OMR-PM-1)
• Nursing Home Transition Program Referral Form (GW-REF)   

Medicaid Managed Care Member Reenrollment

• Medicaid Managed Care Member Reenrollment Member Request Form

Notice of Privacy Practices:

• Notice of Privacy Practices

Personal Needs Fund:

• Personal Needs Fund Regulations
• Personal Needs Fund Authorization Document
• Exhibit B 
• Exhibit C