PM 02-04-00

Use the following application forms for the programs indicated:

Form 683 Application for SNAP benefits
Form 2378B Application for Cash, Medical and SNAP Benefits
Mail-in or DHS web application for all programs.
Form 2378C

Application for Cash, Medical and SNAP Benefits 

All programs.

Form 2378H Mail-in Application for Medical Benefits
Mail-in application for all medical programs. Can also be used by a hospital, long term care facility, or supportive living facility.
Form 2378KC Application for All Kids, FamilyCare and Moms & Babies Health Insurance
Mail-in or Online application for Family Health Plans.
Form 2378M Application for Payment of Medicare Premiums, Deductibles and Coinsurances
Medicaid payment for Medicare cost sharing expenses only.
Form 2378MC Application for All Kids, FamilyCare and Moms & Babies Health Insurance
Medical application for Family Health Plans used by All Kids Application Agents.
Form 2431 Application for Medical Assistance - Short Form
Use this application only for persons who were in spenddown status within the last 4 months of the month of application and were centrally canceled due to not meeting their spenddown obligation.
Form 3089 All Kids Moms & Babies (Medicaid Presumptive Eligibility Application)
Mail-in application used by qualified providers.
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HFS All Kids and FamilyCare Online Application

HFS All Kids and FamilyCare Online Applications are sent to the HFS All Kids Unit only. These applications can be identified by the 14-digit household ID number printed in the upper right-hand corner of each page. Some of the features of the HFS online application are listed below:

  • A secure Internet connection ensures confidentiality of personal information.
  • Applications are assigned a unique household ID number, and applicants will create a password to begin the application process.
  • Applicants may save a partially completed application. They may reopen their saved application using their Household ID number and password up to 16 days from the last time they saved it. AKAAs can reopen a saved application for up to 32 days from the last time they saved it.
  • The online application system reviews the applicant's responses for missing or inconsistent answers. Edits ensure all appropriate fields are completed before the application is submitted. These edits prevent incomplete applications from going to AIS.
  • The application sent electronically updates fields in AIS and appears as a suspended screening in the All Kids Unit's subsystem.