Medicaid Eligibility Other Forms Library

Other Medicaid Forms

Authorization for Verification of Resources (AVS)
Authorization for Verification of Resources Form	Spanish	Vietnamese
Confidentiality Forms
Authorized Representation Allows another person to act on your behalf.	Spanish	Vietnamese
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 (pending update) 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.
Voter Registration Poster Information about how to register to vote.	Spanish	Vietnamese

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

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