Applications & Forms
Applications & Forms
The following applications and forms are used by professionals who work with low-income families. Some forms are available in multiple languages.
WithinReach is here to help professionals connect their clients to health insurance. For more information about applying on Washington Healthplanfinder:
- Call the Family Health Hotline at 1-800-322-2588
- Visit our Benefit Finder
Health Insurance Programs
Under the ACA, individuals and families now apply for health care coverage through Washington State’s Exchange called Washington Healthplanfinder. Free, low cost and market rate health insurance is available through this single portal for Washington residents.
- Apply online at Washington Healthplanfinder
- Call the Exchange Call Center at 1-855-WAFINDER
- Review the paper application for Health Care Coverage
- Access the paper application in 8 other languages (Form # is 18001P)
Health Care Coverage for Pregnant Teens
To be eligible, a pregnant teen must be a Washington State resident under age 19. There is no income limit for the program. Pregnant teens in this program will be treated as an independent household and will not need to provide their parent’s income or financial information.
To apply, please complete the paper application below:
Application for Pregnant Teen Health Care Coverage
MAIL the completed application to:
Medical Eligibility Determination Services
PO Box 45531
Olympia, WA 98504-5531
Please Note: You do NOT apply for pregnant teen coverage on Washington Healthplanfinder. For more information or help applying, call the Apple Health Hotline toll-free at 1-877-543-7669.
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.
- 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.
- 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
- 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.