Other Medicaid Forms
Authorization for Verification of Resources (AVS) |
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Spanish | Vietnamese | |
Confidentiality Forms |
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Allows another person to act on your behalf. |
Spanish | Vietnamese |
Notice of privacy practices. |
Spanish | Vietnamese |
Authorization to release health information to any provider. |
Spanish | Vietnamese |
Authorization to release or obtain health information naming a specific provider. |
Spanish | |
General consent to release health information. |
Medicaid Flyers & Posters |
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About health coverage for people who were in foster care. |
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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. |
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Provides a general summary of each of the Medicaid Programs. |
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A summary of qualifications for coverage and services offered. |
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Information about how to register to vote. |
Spanish | Vietnamese |
Other Forms |
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A form to set aside assets to be used for burial. |
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MS- Social Information Interview A questionaire about an adult's medical condition. |
Spanish | |
MS/C - Child's Medical and & Social Information A questionaire about a child's medical condition. |
Spanish | Vietnamese |
A form for your employer to complete if you do not have proof of your wages. |
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A form used to obtain wage information of a Medicaid applicant whenever they are unable to provide this information. |
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A form used to obtain wage information of a Medicaid Purchase Plan applicant whenever they are unable to provide this information. |