Other Medicaid Forms

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Confidentiality Forms

   

Authorized Representation

Allows another person to act on your behalf.

How to use this form

   

HIPAA 101

Notice of privacy practices.

Spanish Vietnamese

HIPAA 202L

Authorization to release health information to any provider.

Spanish Vietnamese

HIPAA 402P

Authorization to release or obtain health information naming a specific provider.

Spanish  

Waiver of Confidentiality

General consent to release health information.

How to use this form

   
     

Medicaid Flyers & Posters

   

Former Foster Care

About health coverage for people who were in foster care.

   

LaCHIP Outreach Flyer

About how to apply for the LaCHIP program. A listing of program limits are provided.

 Spanish  

Medicaid Eligibility Card

About the Medicaid card.

   

Medicaid Programs Flyer

Provides a general summary of each of the Medicaid Programs.

   

Take Charge Plus Flyer

A summary of qualifications for coverage and services offered.

   Vietnamese

Voter Registration Poster

Information about how to register to vote.

Spanish   
     

Other Forms

   

Burial Fund Designation

A form to set aside assets to be used for burial.

   

MS- Social Information Interview

A questionaire about an adult's medical condition.

How to use this form

MS Supplement A-work history continued

 Spanish  

MS/C - Child's Medical and & Social Information

A questionaire about a child's medical condition.

How to use this form

 Spanish  Vietnamese

Personal Wages

A form for your employer to complete if you do not have proof of your wages.     

How to use this form

   

Wage Verification Request

A form used to obtain wage information of a Medicaid applicant whenever they are unable to provide this information.                                              

How to use this form

   

Wage Verification Request-MPP

A form used  to obtain wage information of a Medicaid Purchase Plan applicant whenever they are unable to provide this information.                   

How to use this form