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Eligibility Management (Income Maintenance) Home >> IM Forms

SeniorCare Forms Sorted by Form Title

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 Title Form Number Form Type Revised Date Language Text
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 English
SeniorCare Instructions for Application Form - Hmong (PDF, 128 KB) F-10076AH PDF 9/1/2011 Hmong
SeniorCare Instructions for Application Form - Spanish (PDF, 124 KB) F-10076AS PDF 9/1/2011 Spanish