Important information for you to know about your application This application is a request for help from the Medicare Savings Programs only. All the information given on this form is confidential and will only be used to administer the programs and will only be disclosed as permitted by law. The Social Security numbers of everyone receiving or requesting assistance will be used to verify identity and eligibility. Social Security numbers will be checked against government databases, as permitted by law. Information provided on this form may be verified to the extent permitted by law, including by checking government computer databases or directly with third parties such as employers or banks. If you need a reasonable accommodation or special help If you cannot do something we ask you to do because you have a disability, you may request a reasonable accommodation or special help. For example, we may be able to complete your application over the telephone if you cannot come into the office, help you get certain proofs, or give you extra time to provide information. Contact DSS at 1-855-626-6632 to request a reasonable accommodation or special help. If we do not agree to give you a reasonable accommodation or special help based on your disability, you can complain to the department’s Americans with Disabilities Act (ADA) coordinator. See the Non-Discrimination Statement on page 4. Please read carefully and sign below I give permission to DSS, or any health insurer, provider, or any other entity providing services to me or my family under the Medicaid program, to release information about me or my family as necessary for the delivery of Medicaid program services and the administration of the Medicaid program, as permissible by federal or state law. I certify under penalty of perjury that all the statements made on this form are true and complete to the best of my knowledge. I understand that I can be criminally or civilly prosecuted under state or federal law if I knowingly give incorrect information or fail to report something I should report. Any person who helped you complete this form or completed this form for you must also sign. Applicant’s Signature Date Spouse’s Signature Date
Helper or Representative’s Signature
Date
Relationship To Applicant
Permission to Share Information To permit the Department of Social Services to share information about your application, please identify the authorized individuals, agencies, or institutions that DSS may communicate with, and sign in the box.
Name:
Phone #
1
Address:
Name:
Phone #
2
Address:
Applicant’s Signature or Signature of Authorized Representative
Date
Page 3 of 4
Return to: PO Box 1320, Manchester, CT 06045
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