PM 02-04-00

Use the following application forms for the programs indicated:

Form 683 Application for SNAP benefits
New TextForm 2378ABE Application for Health Coverage & Help Paying Costs
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 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.

revised text Application for Benefits Eligibility (ABE)

Applicants submit applications for Cash, Medical, Medicare Savings Program, and SNAP through Application for Benefits Eligibility (ABE) at and the applications are routed to the IES at the correct office and retrieved from the Electronic Document Mangement (EDM) Inbox. ABE auto populates screens in the Integrated Eligibility System (IES) worker portal.

Telephonic Applications

Persons may apply for medical and SNAP benefits over the phone by calling the ABE (Application for Benefits Eligibility) Customer Call Center, located in the Broadway Central Family Community Resource Center (FCRC) #150.

The ABE Customer Call Center accepts applications for Medical and initial SNAP only.  The ABE Customer Call Center does not accept telephonic applications for TANF Cash, AABD Cash, or initial SNAP applications if there is an active categorical case with the same grantee.

The ABE Customer Call Center is accessed by calling the DHS helpline at 1-800-843-6154. Telephonic applications taken by the ABE Customer Call Center are processed in the Integrated Eligibility System (IES). If the applicant is not requesting cash assistance or does not have an active medical case, a new application will be started in IES.  ABE Call Center staff will inform the customer at the beginning of the call that a telephonic signature will be required in order to have a valid application.  If the applicant in non-English/non-Spanish speaking, the ABE Customer Call Center contacts the Translator Bank to assist in completing the application interview.