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:

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.

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.

DSHS Consent Form and Client Rights and Responsibilities

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

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

Income Verification Forms

Change of Circumstance (Address or Income) Forms

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

All Electronic Forms Index

DSHS – all electronic forms
Medicaid – all electronic forms