Non-Division of Health Care Access and Accountability IM Forms

This page contains links to forms maintained by the Department of Workforce Development (DWD) or other non-DHS agencies that are needed by Eligibility Management workers.

F-20919 (PDF, 18KB) Medicaid Waiver Eligibility and Cost Sharing Worksheet
F-20919D (PDF, 28KB) Declaration Regarding Transfers of Resources
G 845 (exit DHS) Document Verification Request (SAVE Agencies)
G 845 Supplement (exit DHS) Document Verification Request Supplement (SAVE Agencies)
F-09002 (FNS 135)  Affidavit of Return or Exchange of Food Coupons
F-82009 (Word, 43KB)
DHS Word Document
Confidential Information Release Authorization
Last Revised: June 29, 2015