Applications & Forms

Download or Fill-in Blank Applications

The following applications and forms are used by professionals who work with low-income families. Some of the applications and forms are available in multiple languages.

Fill-in Applications

Type your client’s information onto the application on your computer and print it out.

• Children’s Health Insurance – Medicaid & S-CHIP – Apple Health for Kids
• First Steps – Pregnancy Medicaid
• Basic Food – Food Stamps – (use this application for cash and Family Medical)
• Basic Health has a waiting list to get enrolled – register for the Wait List
• WIC Nutrition Program – there is no application – use the WIC Search Tool to find your client’s local WIC office.
• RENEWAL Form for Children’s Health Insurance

Download & Print Blank Applications (PDF)

• Children’s Health Insurance (Apple Health for Kids) – Medicaid & S-CHIP
  • English
  • Spanish
  • Russian
  • Vietnamese
  • For other languages, select form 14-380 from the DSHS Electronic Forms webpage
    
    
  • Information Sheet – a summary of the free and low cost health insurance programs for children under age 19 and simple directions on how to apply

• RENEWAL Form for Children’s Health Insurance
  • English
  • Spanish
  • Russian
  • Vietnamese
  • For other languages, select form 13-836 from the DSHS Electronic Forms webpage

• First Steps – Pregnancy Medicaid
  • English
  • Spanish
  • Russian
  • Vietnamese
  • For other languages, select form 14-429 from the DSHS Electronic Forms webpage

• Hey Mom! – Filing for medical for babies born to moms on Medicaid
  • English

• Application for Benefits (can be used for food, cash, and Family Medical)
  • English
  • Spanish
  • Russian
  • Vietnamese
  • For other languages, select form 14-001 from the DSHS Electronic Forms webpage
    
    
  • Information Sheet – a summary of the Basic Food (Food Stamps) program and simple directions on how to apply and
  • Helpful Hints on using your EBT Card

Download & Print Authorization Forms (PDF)

The following are authorization forms to assist clients in the application process.

• DSHS Authorization Form
  • English
  • Spanish
  • Russian
  • Vietnamese
  • For other languages, select form 17-063 from the DSHS Electronic Forms webpage

Additional Forms:

• Income Verification
  • Self-employment worksheet – Use this income form if you are self-employed
  • Employment Verification – Employers can verify your income using this form
  • Stop Work Form – If you stopped work due to a lay-off, temporary status, leave, etc. have your recent employer fill out this form

• Change of Circumstance Form – report an address, income, etc. change
  • English
  • Spanish
  • Russian
  • Vietnamese
  • For other languages, select form 14-076 from the DSHS Electronic Forms webpage

• Statement of Shared Living Arrangement – explains how the people who live at an address share expenses

• Statement from Landlord/Manager – provides proof of housing costs

• DSHS Client Rights and Responsibilities – what your client needs to know about applying for and receiving benefits from DSHS

• Head Start – Free preschool – Head Start Program Locator

• Early Childhood Education and Assistance Program (ECEAP) – Free preschool
  • English
  • Spanish
  • Russian
  • Vietnamese
  • Somali

• Free and Reduced School Lunch Form

All Other Forms

• DSHS – all forms
• Basic Health – all forms