Medicaid Forms/Applications - Virginia Department of Social Services

Virginia Department of Social Services

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	Medicaid Forms/Applications
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Applications by Category

Children Under Age 19

Apply Online Through CommonHelp (Web page)
Application for Benefits (PDF)
Application for Benefits (Spanish) (PDF)
Families & Children Medicaid & FAMIS Plus Renewal (PDF)
Health Insurance Application for Children & Pregnant Women (Web page)

Parents & Caretakers of Dependent Children

Apply Online Through CommonHelp (Web page)
Application for Benefits (PDF)
Application for Benefits (Spanish) (PDF)
Families & Children Medicaid & FAMIS Plus Renewal (PDF)

Pregnant Women

Apply Online Through CommonHelp (Web page)
Application for Benefits (PDF)
Application for Benefits (Spanish) (PDF)
Health Insurance Application for Children & Pregnant Women (Web page)

Supplemental Security Income (SSI) Recipients

Apply Online Through CommonHelp (Web page)
Application/Redetermination for Medicaid for SSI Recipients (PDF)

Adults Aged 65 or Older, Blind or Disabled (not receiving SSI)

Apply Online Through Commonhelp (Web page)
Aged Blind Disabled Medicaid Renewal (PDF)
Application for Adult Medical Assistance (PDF)

Children or Adults Who Need Long-term Care in a Facility/Home & Community-based Care (Waiver) Services

Apply Online Through CommonHelp (Web page)
Aged Blind Disabled Medicaid Renewal (PDF)
Application for Adult Medical Assistance (PDF)

Medicare Beneficiaries

Apply Online Through CommonHelp (Web page)
Aged Blind Disabled Medicaid Renewal (PDF)
Application for Adult Medical Assistance (PDF)

Plan First - Family Planning Services

Apply Online Through CommonHelp (Web page)
Plan First Application (Web page)

Forms - All Other

Affidavit of Identity for Medicaid Applicants/Recipients Residing in an Institution (PDF)
Application for Birth Certificate (Web page)
Asset Transfer Undue Hardship Claim (PDF)
Benefit Programs Brochure (PDF)
Burial Fund Designation (PDF)
Medicaid Funded Long-term Care Service Authorization (PDF)
Notification of Change (DOC)

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