Washington Apple Health Classic: Washington Connection

• First name (Self)

• M.I. · optional

• Last name

• Client ID number (If applicable) · optional

• Signature of applicant or authorized representative

• Address where you live (Required) · optional

• County · optional

• City · optional

• State · optional

• Zip code · optional

• Check this box if you do not have a physical address · optional

• Mailing address (if different) · optional

• County · optional

• City · optional

• State · optional

• Zip code · optional

• Primary phone number · optional

• Cell · optional

• Email · optional

• Name of facility · optional

• Address of facility · optional

• County · optional

• City · optional

• State · optional

• Zip code · optional

• I, my spouse, or someone in my household is applying for: · optional

  7 choices

• Do you or anyone you are applying for need help paying for unpaid medical bills incurred in any of the 3 months immediately before the current month? · optional

  Yes · No

• If yes, list who: · optional · if it applies

• Will you or anyone you’re applying for need an interpreter or to receive documents in another language? · optional

  Yes · No

• If yes, what language or alternative format do you need? List all that apply: · optional · if it applies

• In the past 30 days, I, my spouse, or someone in my household received health care coverage from another state, tribe or other source? · optional

  Yes · No

• If yes, explain · optional · if it applies

• I, my spouse, or someone in my household received Supplemental Security Income (SSI) in another state? · optional

  Yes · No

• If yes, who? · optional · if it applies

• I, my spouse, or someone in my household is a sponsored immigrant? · optional

  Yes · No

• If yes, who? · optional · if it applies

• I, my spouse, or someone in my household has served in the U.S. (full text under What you agree to) · optional

  Yes · No

• If yes, who? · optional · if it applies

• I have a tax dependent I have not yet included on my application who does not live with me? · optional

  Yes · No

• If yes, list tax dependent’s name(s) · optional · if it applies

• I am: · optional

  7 choices

• I, my spouse, or someone I am applying for has income from work · optional

  Yes · No

• I, my spouse, or someone in my household receives income from an annuity investment? · optional

  Yes · No

• Rent · optional

• Mortgage · optional

• Space rent · optional

• Homeowners ins. · optional

• Property taxes · optional

• Other expenses · optional

• Do you receive help from another person or agency, such as subsidized housing that pays all or part of these expenses? · optional

  Yes · No

• If yes, who? · optional · if it applies

• I, my spouse, or someone I am applying for has a disability and is working and has expenses that support employment? (full text under What you agree to) · optional

  Yes · No

• If yes, give IRWE amount · optional · if it applies

• I, my spouse, or someone I am applying for has sold, traded, given away, or transferred a resource in the last five years (including property trusts, vehicles, cash, or life estates)? (full text under What you agree to) · optional · if it applies

  Yes · No

• I/we have long-term care insurance? · optional

  Yes · No

• Is this a qualified LTC Partnership (LTCP) policy? · optional

  Yes · No

• Are you designating an authorized representative? · optional

  Yes · No

• Do you want your authorized representative to receive notices related to your application and account? · optional · if it applies

  Yes · No

• Does this authorized representative have legal guardianship · optional · if it applies

  Yes · No

• If yes, for who: · optional · if it applies

• Does this authorized representative have power of attorney? · optional · if it applies

  Yes · No

• If yes, for who: · optional · if it applies

• Authorized representative name / organization · optional · if it applies

• Phone number · optional · if it applies

• Email address · optional · if it applies

• Mailing address of authorized representative · optional · if it applies

• Do you want to register to vote or update your voter registration? · optional

  Yes · No

• Do you want to be automatically registered to vote? · optional

  Yes · No

• Signature of client

• Phone number · optional

• Date · optional

• Signature of spouse · optional

• Phone number · optional

• Date · optional

• Signature of parent for minor child client · optional

• Phone number · optional

• Date · optional

• Signature of authorized representative or helper · optional

• Phone number · optional

• Date · optional

Information about you and your family: answered for each person (Name (First, Middle, Last), Sex assigned at birth, Relation to you?, Date of birth, Social Security number (SSN)*, Do you want coverage for this person?, U.S. citizen, Washington resident, Are you Hispanic, Latino, or Spanish origin?, Race (OPTIONAL – select up to five that apply)).

Employment or self-employment income (Attach proof): answered for each person (Who earns this income:, Employer’s name, Employer’s phone number, Is this job self-employment?, Start date, Gross amount received (Dollar amount before deductions), Hours per week, Pay dates (e.g. 1st and 15th, or every Friday), every:).

Other Income (For all household members) (Attach proof): answered for each person (Other income type, Who gets the income, Gross monthly amount).

Other Income (For all household members) (Attach proof): answered for each person (Who owns the annuity, Company or institution, Amount or value, Monthly income, Date purchased).

Child or adult dependent care: answered for each person (Monthly amount, Who pays).

Court ordered child support: answered for each person (Monthly amount, Who pays).

Payee fees: answered for each person (Monthly amount, Who pays).

Guardianship fees: answered for each person (Monthly amount, Who pays).

Court ordered attorney fees: answered for each person (Monthly amount, Who pays).

Recurring medical expenses: answered for each person (Monthly amount, Who pays).

I, my spouse, or someone I am applying for owes medical expenses?: answered for each person (Medical expense type, Date incurred, Amount owed, Who owes).

Resources (Attach Proof): answered for each person (Resource type, Who owns, Location, Value).

Resources (Attach Proof): answered for each person (Year (e.g., 2010), Make (e.g., Ford), Model (e.g., Escort), Amount owed, Check if leased, Check if used for medical purposes).

Additional LTSS Resources (Complete only if you are applying for LTSS services): answered for each person (Property address, Current value (Per assessor), Loan amounts owed on property).

Additional LTSS Resources (Complete only if you are applying for LTSS services): answered for each person (Type of resource, Date of transfer, Value of resource transferred, Who was it transferred to).

Long-Term Care Insurance (Not needed for Medicare Savings Programs): answered for each person (Insurance company, Policy number, Policy holder's name, Covered person, Dollar value (if LTCP)).

• You may start with a partial application with your name, address and signature. The agency needs a completed application before it makes a final decision.
• The agency can contact you for verification. Ask for help if you cannot get a requested document.
• The agency generally gives a written decision within 45 days. Some disability cases take up to 60 days. Pregnancy medical has a 15-day limit.
• If you do not give requested information or ask for more time, the agency may deny, close or change coverage.
• The agency gives you 10 calendar days to provide needed information and gives more time if you ask.
• In most cases, the agency notifies you at least 10 days before stopping coverage.
• You can ask for an administrative hearing if you disagree with a decision. You may also ask a supervisor to review it without losing hearing rights.

• List yourself, your spouse and dependents who live with you, even if you are not applying for all of them.
• Skip resources if you apply only for Medicare Savings Programs or HWD.
• Attach housing expense proof if you apply for LTSS.
• Mail or fax LTSS requests to Home and Community Services. The form gives a different destination for other Classic requests.

• HCA currently gives application methods without a seasonal window. No closing date is stated.
• Front Door research owns this draft. Re-read the forms, rules and windows by October 18, 2026, and before publication.
• This is a partial capture of the 18-page HCA 18-005. Repeated field templates have not been expanded into every printed slot or measured PDF box. No new live recipe is ready.
• The schema has no help-text field, row identity, nested repeated groups, option-level conditions, or maximum number of selected choices. Race allows up to five choices. Original instructions and every row remain in the cached form.
• The scalar fact types cannot store a set of selected programs or races. The resources exemption applies when applying only for MSP or HWD, LTSS resources apply only to LTSS, and long-term care insurance is not needed for MSP. Review conditions before intake.
• Washington Connection account questions, online validations and electronic signatures were not traversed. Only the blank official form was captured. No synthetic person was entered or submitted.
• The CN screener uses proposed counted SSI income, counted resources and a reviewed standard basis. Existing gross income, food-household size, age65 and household disability facts cannot substitute for these applicant-specific determinations.
• Spenddown, special income exclusions, trusts, annuities, spouse deeming, functional LTSS assessments, estate recovery, Medicare Savings Programs, HWD, TSOA and state-funded or emergency routes are not fully screened. Failure of the ordinary CN financial route remains maybe for other Classic routes.
• The form says Attach proof for earned income, other income and resources, and for housing expenses when applying for LTSS. It does not specify a complete accepted-document list, date limits or all exemptions. Document checklist entries preserve these limits and do not invent proof alternatives.
• SSI-related asset verification requires the resident’s authorization. TSOA is exempt from denial for refusing that authorization. The draft cannot collect or grant consent on behalf of the resident.
• The paper form accepts requests for three prior months of unpaid bills. Individual retroactive eligibility, spenddown and effective dates still require agency review.