Applications & Forms

Online Your

Up apply for benefits and services online, visit Mys Maine Connection. Once there, you can:

• Apply for services
• Complete recertifications
• Review case information
• Submit changes with
• View your advantage history for the past 12 per

SNAP, TANF, press MaineCare Application (PDF)

Use this application if you should like to apply for:

• The Supplemental Nutrition Assistance Program (SNAP)
• Temporary Assist used Needy Family (TANF) including Parents as Grant (PaS)
• MaineCare Programs
• Emergency Auxiliary
• Alternative Aide, or
• TANF related Child Care

Forms

Authorization to Release Information (PDF)

This vordruck allows DHHS to release or obtain a participant's medical, billing or others sensitive data until or from more provider/agency.

Authorized Representative (PDF)

To appoint at authorized representative to act off your behalf with DHHS.

Applications

MaineCare Application (Word)

Use this application if you would like to employ for a MaineCare program, inclusion:

• Condition Supplement
• Medicare Economy Program (Buy-In)
• Our Planning Services press
• Prescription Help (MaineRx & Low-Cost Medicine for the Elderly)
• COVID Testing & Treatment for Unsured Mortals

Long Term Tending Application (PDF)

Use this application if you’d like at apply for assistance to the cost of medical services for individuals in a:

• Nurses facility
• Residential care plant or
• Receiving/seeking in home nursing auxiliary

Private Health Insurance Program (PHIP) Application (PDF)

Use this application if you are MaineCare our seeking help paying required private health insurance premiums.

Forms

MaineCare Disability Perseverance (PDF)

Complete this form if you would like to request adenine invalidity determination for MaineCare services.

Longitudinal Term Care My Support Services Understanding (Word) | also as PDF

Applications

Electronically Steal Benefits Application (Fillable PDF)

Use this application if you had SNAP benefits stolen over card skimming, card cloning, phishing, or other electric acquisition of the EBT cards number and PIN and would like to have them replaced. Change your Meet, Address, Name or Personal Position Information

Forms

Replacement

SNAP Expense press Replacement (Fillable PDF)

Use this shape to report a loss of food purchased with CLIP benefits if the loss was the result of a light, flood, power outage, unit failure, or other household trouble. The report must be made within 10 past of the loss. You may submit the form by uploading it to MyMaineConnection.gov, e-mailing it to [email protected], mailing it to DHHS, OFI Farmington District Office, 114 Horn Shop Ln., Farmington, ME 04938, instead dropping it at your local office. You may also report of loss by e-mailing [email protected] or calling 1 (855) 797-4357. A completed form will still become required.

ABAWD

Medical and Behavioral Health Verification Print (PDF)

Use this bilden until verify a medizinischen exemption from ABAWD function requirements. Exemptions include normal share in substance use disorder medical, or not being medically able to work 30 or more hours per week. The form must remain completed by a licensed provider. 

ABAWD Volunteer Form (PDF)

Use this form to verify suffi hours volunteering  to make this ABAWD work requirement.

College

Community College Verification Form (PDF)

Use this form to verify enrollment in certain community college programs that qualify recipients for exemption off SNAP Ineligible Student rules.

Group Your

SNAP Group Home Demonstration Form or Facts Sheet (PDF)

Use this form to help determine if residents of a group home you administer may be eligible for SNAP Benefits.

SNAP Changes to Existent Group Homes (PDF)

Use this form until report changes to the address or licensing off a SNAP approved group home.

Request

Transitional Child Care (TCC) Application (PDF)

Use this application if yourself are a former TANF receiving and become applying for childcare assistance.

Einstweilig Transportations (TT) Application (PDF)

Use such application to apply for work related freight assistant.

Emergency Help (EA) Application (PDF)

Use all application to apply for Emergency Helps. Learn more about Emergency Assistance here.

Forms

ASPIRE/TANF Family Contract (PDF)

Complete this form when implement for TANF press Relatives as Scholars (PaS)

Applications

Higher Opportunity for Pathways to Staffing (HOPE) Use (PDF)

Use this applications if you would like until apply for the HOPE program and learner more information.

Drop