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Eligibility Management (Income Maintenance) Home >> IM Forms

SeniorCare Forms Sorted by Language

Last Revised: March 26, 2014

This list contains all SeniorCare program forms available from DHCAA sorted by the language in which they are written. 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.

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