• Resources
• LDH Resources

LDH Resources

• BHSF Form AC-7 - RightFAX Cover and Transmittal Log

  Details:

  June 24, 2021

  • Medicaid

  Application Center Forms

  Downloadable Assets:

  BHSF Form AC-7 - RightFAX Cover and Transmittal Log BHSF Form AC-7 - RightFAX Cover and Transmittal Log - Instructions

• Provider Request for Eligibility Status

  Details:

  May 03, 2021

  • Medicaid

  Application Center Forms, Medicaid Provider Forms, Medicaid Forms Library

  Downloadable Assets:

  Provider Request for Eligibility Status

• Long-Term Care Application

  Details:

  March 15, 2021

  • Medicaid

  Application Center Forms, Medicaid Applications, Medicaid Forms Library

  Downloadable Assets:

  Long-Term Care Application Long-Term Care Application - Spanish Long-Term Care Application - Vietnamese

• BHSF Form AC-8 - Satellite Location Inspection/Monitoring Report

  Details:

  April 28, 2020

  • Medicaid

  Application Center Forms

  Downloadable Assets:

  BHSF FORM AC-8 - Satellite Location Inspection/Monitoring Report

• BHSF Form MS-C - Child's Medical and Social Information

  Details:

  April 27, 2020

  • Medicaid

  Application Center Forms, Medicaid Forms, Other Forms, Other Medicaid Forms, Medicaid Forms Library

  Downloadable Assets:

  BHSF Form MS-C - Child's Medical and Social Information BHSF Form MS-C - Child's Medical and Social Information - Spanish BHSF Form MS-C - Child's Medical and Social Information - Vietnamese BHSF Form MS-C - Child's Medical and Social Information - Instructions

• Application Center Handbook

  Details:

  February 11, 2020

  • Medicaid

  Application Center Forms

  Downloadable Assets:

  Application Center Handbook

• Voter Registration Declaration

  Details:

  October 18, 2019

  • Medicaid

  Application Center Forms

  Downloadable Assets:

  Voter Registration Declaration Voter Registration Declaration - Spanish Voter Registration Declaration - Vietnamese

• Authorization for Verification of Resources Form

  Details:

  October 02, 2019

  • Medicaid

  Application Center Forms, Medicaid Forms, Other Medicaid Forms, Medicaid Forms Library

  Downloadable Assets:

  Authorization for Verification of Resources Form Authorization for Verification of Resources Form - Spanish Authorization for Verification of Resources Form - Vietnamese

• Verification Form - Application Verification Request Form

  Details:

  August 16, 2019

  • Medicaid

  Application Center Forms

  Downloadable Assets:

  Verification Form - Application Verification Request Form Verification Form - Application Verification Request Form - Instructions

• Former Foster Care Flyer

  Details:

  March 06, 2018

  • Medicaid

  Application Center Forms, Medicaid Forms, Other Forms, Other Medicaid Forms, Medicaid Flyers Posters, Medicaid Forms Library

  Downloadable Assets:

  Former Foster Care Flyer

• Health Plan Non-Timely Filing Procedures

  Details:

  September 05, 2017

  • Medicaid

  Application Center Forms, Flyers, Posters

  Downloadable Assets:

  Health Plan Non-Timely Filing Procedures

• Medicaid Eligibility Outstation Worksheet

  Details:

  November 12, 2016

  • Medicaid

  Application Center Forms

  Downloadable Assets:

  Medicaid Eligibility Outstation Worksheet