Healthcare Application For The Elderly And Disabled

Download a blank fillable Healthcare Application For The Elderly And Disabled in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Healthcare Application For The Elderly And Disabled with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.


Case Number:
Date Requested:
SFN 958 (3-2016)
Date Received:
Interview Date:
If you are not elderly or disabled and wish to apply for
Health Care Coverage, complete the Application for
Case Number:
Health Care Coverage (SFN 1909) or the Application for
Assistance (SFN 405).
Instructions For Application For Health Care Coverage
This application may be used to apply for Health Care Coverage, the Medicare Savings Programs, Aid
to the Blind, or Basic Care. See the Guidebook for more information.
What Do I Need to Do to Get Health Care Coverage?
Follow these steps to apply for Health Care:
Check the assistance for which you are applying
(Check ALL that apply).
Step 1:
If you would like more information on these programs, see the Application for
Assistance Guidebook. If you did not receive the Guidebook, contact your local social
service office.
Health Care Coverage –
Medicaid coverage for the elderly and disabled.
Aid to the Blind –
Assists with treatment for people who are not eligible for Medicaid and are
in danger of losing their vision or require restorative eye services.
Medicare Savings Programs –
Assists with Medicare Part B premium, coinsurance
and deductibles.
Basic Care Assistance –
Helps pay for room and board and personal care in licensed
basic care facilities.
Step 2:
Answer as many questions as you can.
If you need help applying for
assistance, you may have a friend, relative, or someone else help you apply. Your local
county social service office can also help you apply for assistance. If you need additional
space, attach a separate sheet of paper.
Step 3:
Sign and Return
the completed application to your local county social service office.


00 votes

Related Articles

Related forms

Related Categories

Parent category: Medical
Page of 10