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Name SS W-1 LTC New 07-2013 Page 1 of 21 State of Connecticut Department of Social Services Long-term Care/Waiver Application Client ID Items Needed for Your Long-Term Medical Care / Home Care Application KEEP PAGES 1 and 2 FOR YOUR RECORDS If you do not already get Long-Term Care Medical Assistance or Home Care Assistance from the Department of Social Services we need the items listed below to process your application. Send copies do not send originals. In some cases we may request more...
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KEEP A PHOTO TO COMPLETE YOUR APPLICATION This is not currently required if applying on your own, but it may be required if we have already received other information from you. This may include a letter or note from a doctor, mental health provider, social worker or other appropriate provider. Please send copies, do not send originals. — Birth certificate for child/grandchild (if not already received) — Court order with Social Security number NOTE: The Court order must be notarized and dated on or before March, 14, 2005, or this is not considered your official Court order. Please see: for information on obtaining a document with a non-fictitious date and signature, such as a Social Security number or a State issued identification card. If you do NOT have a document (notarized, date or signature) required by the Court, this will not be accepted. The Clerk will notify you after the Court issued the document the Court order (you are NOT required to have a copy of the document to obtain Long-Term Care/Home Care benefits after March, 14, 2005.) It is recommended that you get a photocopy. Copies need to be: 8-1/4" by 11" or larger (not a larger size than 8 1/2" by 11"). A single copy is fine for two people. — Lawyer — Lawyer to sign the copy — Letter (if you do not have a letter). — Medical documentation: A copy of your Medicaid/Long-Term Care Card (only if you have it) or Insurance Card (must be from January 1, 2005, or later). Copies also need to be 2" by 3 1/2” — larger than your current photo (the current photo is what we use in our applications) NOTE: If you do NOT have a Medicaid/Long-Term Care Card or insurance card, you cannot get Medicaid/Long-Term Care for this reason alone. It is also required if we have already received other information from you.
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