Application Center Forms

Please limit use of the printable application to instances when use of the Self Service Portal is unavailable or impractical.

Application Center Evaluation  
Application Center Handbook

 
General Application  
General Application - Additional Persons  
General Application - Employer Coverage Tool  
General Application - Appendix D - Personal Assets  
General Application - Spanish  
General Application - Vietnamese  
Medicaid Forms Library  
AC-5 (Log of Referrals) Instructions
AC-7 (RightFAX Cover and Transmittal Log)    Updated 6.24.21 Instructions
AC-8 (Inspection / Monitoring Report)   
AC-8a (Monitoring Corrective Action Results) Instructions
AC Signage Template  
AC Signage Template - Spanish  
AR (Consent for Authorized Representation)  Instructions
Clearance (Statement of Applicant) Instructions
Health Plan Non-Timely Filing Procedures  
Healthy LA Comparison Chart - English  
Healthy LA Comparison Chart - Spanish  
HIPAA 202L (Authorization to Release Health Information)  
HIPAA 402P (Authorization to Release or Obtain Health Information) Instructions
Ins-LR (Request for Life Insurance Policy Information) Instructions
LaCHIP Lunch Flyer Spanish
MS (Social Information Interview) Instructions
MS/C (Child's Medical & Social Interview) Instructions
Resources (Request for Resources & Interest Income Information) Instructions
Verification (Application Verification Request Form) Instructions
Voter Registration Application (LR-1 & 1M)

 
Voter Registration Declaration (English)  
Voter Registration Declaration (Spanish)  
Voter Registration Declaration (Vietnamese)  
Voter Registration Poster (English)  
Voter Registration Poster (Spanish)  
Voter Registration Poster (Vietnamese)  
Wages (Personal Wage Record)  Instructions
WIC 38 Flyer