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