Applications & Forms

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.

Health Insurance Programs - Fill-in Applications

Electronic applications.

Apple Health for Kids (Children’s Health Insurance – Medicaid & S-CHIP)

RENEWAL Form for Apple Health for Kids (Children’s Health Insurance)

First Steps (Pregnancy Medicaid) Application

Basic Food (Food Stamps) (Cash and Family Medical) Application

Basic Health enrollment waiting list

WIC Nutrition Program (no application) Find a WIC Clinic Search Tool

Children’s Health Insurance (Apple Health for Kids) – Medicaid & S-CHIP

Applications to print and fill out. Information about Apple Health for Kids and how to apply.

English

Spanish

Russian

Vietnamese

For other languages, select form 14-380 from the Medicaid Forms webpage .

Renewal Form for Children’s Health Insurance

Applications to print and fill out.

• English
• Spanish
• Russian
• Vietnamese

• For other languages, select form 13-836 from the Medicaid Forms webpage

First Steps – Pregnancy Medicaid Application

Applications to print and fill out. Information about the First Steps program and how to apply.

• English
• Spanish
• Russian
• Vietnamese

• For other languages, select form 14-429 from the Medicaid Forms webpage.

Hey Mom Form- sign up for free medical coverage for your baby if you were on the First Steps Program (Medicaid) when your baby was born.

Application for Benefits

Application to print and fill out. The Application for Benefits can be used to apply for Basic Food, Cash Assistance, and the Family Medical programs. Information about the Applications for Benefits and how to apply.

• English
• Spanish
• Russian
• Vietnamese
• For other languages, select form 14-001 from the DSHS Electronic Forms webpage

DSHS Consent Form and Client Rights and Responsibilities

Consent form to give DSHS permission to share information with providers helping clients with DSHS services.

• English
• Spanish
• Russian
• Vietnamese
• For other languages, select form 14-012 from the DSHS Electronic Forms webpage

What your client needs to know about applying for and receiving benefits from DSHS. DSHS Client Rights and Responsibilities.

Income Verification Forms

• Self-Employment Verification Worksheet
• 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 (Address or Income) Forms

• English
• Spanish
• Russian
• Vietnamese
• For other languages, select form 14-076 from the DSHS Electronic Forms webpage Electronic Forms webpage

Statement of Shared Living Arrangement
The Statement of Shared Living Arrangement form explains how the people who live at an address share expenses.

Statement from Landlord/Manager
The Statement from Landlord/Manager form provides proof of housing costs.

Application for Free and Reduced Price School Meals

• English
• Spanish

All Electronic Forms Index

DSHS – all electronic forms
Medicaid – all electronic forms