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Eligibility Management (Income Maintenance) Home >> IM Forms

SeniorCare Forms Sorted by Form Type

Last Revised: March 26, 2014

This list contains all SeniorCare program forms available from DHCAA sorted by the format (Excel, Paper only, PDF, Word). Forms marked as "PDF-Fillable" indicates the PDF form can be filled in using your computer and then printed; see About PDF Forms. If this list includes Microsoft Word or Excel forms, they can be filled in, saved, and transmitted electronically. You must have access to Microsoft Office 97, or a more recent version, to use these forms.

Form Type Form Title Form Number Revised Date Language
Paper SeniorCare Application (PDF, 179 KB) F-10076 10/1/2008 English
Paper SeniorCare Instructions for Application Form (PDF, 71 KB) F-10076A 9/1/2011 English
PDF How the Affordable Care Act may affect SeniorCare members who get Prescriptions (PDF, 62 KB) F-00985 4/1/2014 English
PDF Income Maintenance Quality Assurance (IMQA) Web Request (PDF, 32 KB) F-16083 8/1/2011 English
PDF SeniorCare Authorization of Representative (PDF, 486 KB) F-10080 7/1/2008 English
PDF SeniorCare Instructions for Application Form - Hmong (PDF, 128 KB) F-10076AH 9/1/2011 Hmong
PDF SeniorCare Instructions for Application Form - Spanish (PDF, 124 KB) F-10076AS 9/1/2011 Spanish