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HCA 18-005 (1/23)
Washington Apple Health Application
for Aged, Blind, Disabled/Long-Term Services and Supports
Use this application to see what health care coverage may qualify for if:
• 

• 
• 
• 
• 
• 
Note:

• 
• 
• 
• 
Apply faster online
• 

• 
• 
• 
• 
• 

• 




• 
DSHS
Community Services Division - Customer Service Center
PO Box 11699, Tacoma, WA 98411-6699
• 
• 
• 
• 
• 



• 
DSHS
Home and Community Services
PO Box 45826, Olympia, WA 98504-5826
• 
• 
• 
• 
• 


Health Care Coverage Rights and Responsibilities
Your rights (we must) for all health care coverage programs
 You can contact the Department of Social and Health Services (DSHS) at
1-877-501-2233 for assistance.
at no cost to you and without delay when communicating with DSHS or the
Health Care Authority (HCA).
but we may share some information with other state and federal agencies nancial
institutions, and HCA contractors for purposes of eligibility and enrollment.
 if you disagree with a determination made by DSHS or HCA that aects your eligibility
for health coverage, long-term services and supports (LTSS), or a health plan. If you ask for an appeal, your case will be
reviewed. For information about appeals for DSHS programs, you may contact DSHS Customer Service Contact Center at
1-877-501-2233 or visit your local Community Services Oice.
If the appeal is for a decision on Washington Apple Health coverage, which is unresolved by a case review, you will be
scheduled an Administrative Hearing.
DSHS and HCA comply with applicable Federal civil rights laws and do
not discriminate on the basis of race, color, national origin, age, disability, or sex. DSHS and HCA does not exclude people or
treat them dierently because of their race, color, national origin, age, disability, or sex.
DSHS and HCA also comply with applicable state laws and do not discriminate on the basis of creed, gender, gender
expression or identity, sexual orientation, marital status, religion, honorably discharged veteran or military status, or the use of
a trained dog guide or service animal by a person with a disability.
DSHS and HCA:
• 
• 
• 
• 
• 
• 
If you need these services, contact 1-877-501-2233.
If you believe that DSHS or HCA has failed to provide these services or discriminated in another way, you can le a
grievance with:
• 






• 






You can le a grievance in person or by phone, mail, fax, or email. If you need help ling a grievance, the DSHS Constituent
Services or HCA Division of Legal Services is available to help you.
You can also le a civil rights complaint with the U.S. Department of Health and Human Services, Oice for Civil Rights
electronically at  or by mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD).
Complaint forms are available at .


With some exceptions, you must provide a Social Security Number (SSN) or
immigration document number of yourself or anyone else in your household who wants to apply for health care coverage.
An SSN is required to apply for health insurance premium tax credits. We use this information to determine your eligibility by
conrming your identity, citizenship, immigration status, date of birth, and availability of other health care coverage.
We do not share this information with any immigration agency.
It is possible to apply for coverage for some members of your household, but not others. If you do not have an SSN or
immigration document number for all household members, others can still apply for and get coverage. For example, you
can apply for your child even if you aren’t eligible for coverage. Applying won’t aect your immigration status or chances of
becoming a permanent resident or citizen.
There are also some Washington Apple Health programs for people who cannot show they are in the country legally. But if you
choose not to provide an SSN or immigrant document number for someone in your household, we will need to follow up with
you to get information about the non-applicant's income.
If requested by the agency, provide any information or proof needed to decide if you are eligible.

 that govern the operation of Washington Connection and state-administered
application systems, your rights and responsibilities as someone who uses them and the coverage you get from using them.
By using these systems, you agree to comply with the laws that apply to someone using them and the coverage they get as
a result.
 requires all states to provide voter registration assistance through their
public assistance oices. Applying to register or declining to register to vote will not aect the services or benets that you
will be provided by this agency. You can register to vote at  or order voter registration forms by calling
1-800-448-4881.
 restrictions prevent HCA and DSHS from discussing the
health information of you or any member of your household with anyone, including an authorized representative, unless that
individual has power of attorney or you have signed a consent form authorizing the disclosure of this information. This includes
disclosure of mental health information, HIV, AIDS, STD test results, or treatment and chemical dependency services.
 prevents DSHS and HCA from giving the personally identiable information (PII) of you or any
member of your household to anyone who is not authorized to receive it, and without your consent.
 is subject to verication by federal and state oicials for purposes of
determining your eligibility for health care coverage. Verication can include follow-up contacts from agency sta.
Your health insurance carrier can
provide you more information about your benets. 



To get an application for these services, go to  or contact your local DCS oice.


if you ask.
 that includes at minimum, your name, address, and signature or the signature
of the applicant’s authorized representative. The day we get a partial application is your application date, which may aect
when your coverage becomes eective. We will not make a nal decision about your coverage until aer you complete the
application.
 using any method listed under WAC 182-503-0005.
 and no later than the timelines described in WAC 182-503-0060.
to provide information we need to determine eligibility. If you ask for more time, we will give you
more time. If you don’t give us the information or ask for more time, we may deny, close, or change your health care coverage.
if you have trouble getting any information or proof needed for us to decide if you are eligible. If we require a
document that will cost you money, we will send for it and pay the cost.
before we stop your health care coverage.
 in most cases, within 45 days. Health care coverage for some disability cases may take up to 60
days. We give a written decision on pregnancy medical within 15 days.
 to an investigator if we audit your case. You do not have to let an investigator into your
home. You may ask the investigator to come back at another time. Such a request will not aect your eligibility for health
care coverage.
 while we decide if you are eligible for another program per
WAC 182-504-0125.
 as described in WAC 182-503-0120 if you are eligible.

Report changes as required in WAC 182-504-0105 and WAC 182-504-0110 within 30 days of the change. Read your approval
letter to see what changes you must report.
when asked.
 needed to bill us for health care services.
if you are entitled to it.
sta when asked.
 to get potential income from other sources when you ask for or receive Washington
Apple Health coverage.

you give the state of Washington all rights to any medical support
and to any third party payments for health care.
your child’s immunization history with the Child Prole Immunization Tracking System.
 may be provided to DSHS to determine eligibility and monthly benets for programs such as health
care coverage, cash assistance, food assistance and child care subsidies.


. Estate
Recovery doesn’t happen until aer your death, the death of your surviving spouse, and your surviving children are
age 21 or older. It also doesn’t happen if a surviving child was blind/disabled at your time of death. Recoverable
costs include:
• 

• 
You can nd a list of services subject to cost recovery under WAC 182-527-2742. You can nd a list of assets
excluded from recovery under WAC 182-527-2746.
The State may also le a pre-death lien on your real property, at any age, if you become permanently
institutionalized (WAC 182-527-2734). The State may recover from a sale of the property, or your estate, unless:
• 
• 
• 
• 
You can nd a list of services subject to cost recovery under a pre-death lien in WAC 182-527-2734.
 pharmacy, and/or hospital if you seek out unnecessary
health care services from providers.

HCA 65-153 (3/17)
[English] Language assistance services, including
interpreters and translation of printed materials, are
available free of charge. Call 1-800-562-3022
(TRS: 711).
[Amharic]
የቋንቋ እገዛ አገልግሎት፣ አስተርጓሚ እና የሰነዶችን
ትርጉም ጨምሮ በነጻ ይገኛል
1-800-562-3022 (TRS: 711)
ይደውሉ
[Arabic] نﯾﯾروﻔﻟا نﯾﻣﺟرﺗﻣﻟا كﻟذ ﻲﻓ ﺎﻣﺑ ،تﺎﻐﻠﻟا ﻲﻓ ةدﻋﺎﺳﻣﻟا تﺎﻣدﺧ
مﻗر ﻰﻠﻋ لﺻﺗا ،
ً
ﺎﻧﺎﺟﻣ ةرﻓوﺗﻣ ،ﺔﻋوﺑطﻣﻟا داوﻣﻟا ﺔﻣﺟرﺗو
3022-562-800-1 )TRS: 711.(
[Burmese]
ဘာသာျပန္ဆိုသူမ်ားႏွင့္ ထုတ္ျပန္ထားသည့္
စာရြက္စာတမ္းမ်ားဘာသာျပန္ျခင္းအပါအဝင္
ဘာသာစကားအေထာက္အကူဝန္ေဆာင္မႈမ်ားကို အခမဲ့ရႏိုင္ပါသည္။
1-800-562-3022 (TRS: 711) ကိုဖုန္းေခၚဆိုပါ။
[Cambodian] esvaCMnYyPasa rYmmanTaMg/ñkbkE®bpÊal'mat' nig
karbkE®bGksare◊HBumı KW/acrk◊neday≤tKit´z¬.
ehATUrs¤BÊeTAelx
1-800-562-3022 (TRS: 711).
[Chinese] 免费提供语言协助服务，包括口译员和印制
资料翻译。请致电 1-800-562-3022 (TRS: 711)。
[Korean] 통역 서비스와 인쇄 자료 번역을 포함한 언어
지원 서비스를 무료로 이용하실 수 있습니다.
1-800-562-3022 (TRS: 711)번으로 전화하십시오.
[Laotian]
kanbMrikand™anfaSa, lvmtzgnaYEpfaSa ElA
kanEpewk San†Ifim, mIRv™VH™FrIodYbB˚id˚Æa. otHaelk
1-800-
562-3022 (TRS: 711).
[Oromo] Tajajilli gargaarsa afaanii, nama afaan hiikuu
fi ragaalee maxxanfaman hiikuun, kaffaltii malee ni
argattu. 1-800-562-3022 (TRS: 711) irratti bilbilaa.
[Persian] و دﺎﻧﺳا ﮫﻣﺟرﺗ و ﯽھﺎﻔﺷ مﺟرﺗﻣ ﮫﻠﻣﺟ زا ،ﯽﻧﺎﺑز ﮏﻣﮐ تﺎﻣدﺧ
هرﺎﻣﺷ ﺎﺑ.دﺷ دھاوﺧ ﮫﺋارا نﺎﮕﯾار تروﺻﺑ ،ﯽﭘﺎﭼ (بﻟﺎطﻣ) کرادﻣ
1-800-562-3022 (TRS: 711) .دﯾرﯾﮕﺑ سﺎﻣﺗ
[Punjabi]
— 
   — 
1-800-562-3022
(TRS: 711)
'
[Romanian] Serviciile de asistență lingvistică, inclusiv
cele de interpretariat și de traducere a materialelor
imprimate, sunt disponibile gratuit. Apelați 1-800-562-
3022 (TRS: 711).
[Russian] Языковая поддержка, в том числе услуги
переводчиков и перевод печатных материалов,
доступна бесплатно. Позвоните по номеру
1-800-562-3022 (TRS: 711).
[Somali] Adeego caawimaad luuqada ah, ay ku jirto
turjubaano afka ah iyo turjumid lagu sameeyo
waraaqaha la daabaco, ayaa lagu helayaa lacag
la’aan. Wac 1-800-562-3022 (TRS: 711).
[Spanish] Hay servicios de asistencia con idiomas,
incluyendo intérpretes y traducción de materiales
impresos, disponibles sin costo. Llame al 1-800-562-
3022 (TRS: 711).
[Swahili] Huduma za msaada wa lugha, ikiwa ni
pamoja na wakalimani na tafsiri ya nyaraka
zilizochapishwa, zinapatikana bure bila ya malipo.
Piga 1-800-562-3022 (TRS: 711).
[Tagalog] Mga serbisyong tulong sa wika, kabilang
ang mga tagapagsalin at pagsasalin ng nakalimbag
na mga kagamitan, ay magagamit ng walang bayad.
Tumawag sa 1-800-562-3022 (TRS: 711).
[Tigrigna]
ተርጎምትን ናይ ዝተፅሓፉ ማተርያላት ትርጉምን ሓዊሱ ናይ
ቋንቋ ሓገዝ ግልጋሎት፤ ብዘይ ምንም ክፍሊት ይርከቡ
ብ
1-800-562-3022 (TRS: 711) ደውል
[Ukrainian] Мовна підтримка, у тому числі послуги
перекладачів та переклад друкованих матеріалів,
доступна безкоштовно. Зателефонуйте за
номером 1-800-562-3022 (TRS: 711).
[Vietnamese] Các dịch vụ trợ giúp ngôn ngữ, bao gồm
thông dịch viên và bản dịch tài liệu in, hiện có miễn
phí. Gọi 1-800-562-3022 (TRS: 711).
HCA 65-153 (3/17)
[English] Language assistance services, including
interpreters and translation of printed materials, are
available free of charge. Call 1-800-562-3022
(TRS: 711).
[Amharic]
የቋንቋ እገዛ አገልግሎት፣ አስተርጓሚ እና የሰነዶችን
ትርጉም ጨምሮ በነጻ ይገኛል
1-800-562-3022 (TRS: 711)
ይደውሉ
[Arabic] نﯾﯾروﻔﻟا نﯾﻣﺟرﺗﻣﻟا كﻟذ ﻲﻓ ﺎﻣﺑ ،تﺎﻐﻠﻟا ﻲﻓ ةدﻋﺎﺳﻣﻟا تﺎﻣدﺧ
مﻗر ﻰﻠﻋ لﺻﺗا ،
ً
ﺎﻧﺎﺟﻣ ةرﻓوﺗﻣ ،ﺔﻋوﺑطﻣﻟا داوﻣﻟا ﺔﻣﺟرﺗو
3022-562-800-1 )TRS: 711.(
[Burmese]
ဘာသာျပန္ဆိုသူမ်ားႏွင့္ ထုတ္ျပန္ထားသည့္
စာရြက္စာတမ္းမ်ားဘာသာျပန္ျခင္းအပါအဝင္
ဘာသာစကားအေထာက္အကူဝန္ေဆာင္မႈမ်ားကို အခမဲ့ရႏိုင္ပါသည္။
1-800-562-3022 (TRS: 711) ကိုဖုန္းေခၚဆိုပါ။
[Cambodian] esvaCMnYyPasa rYmmanTaMg/ñkbkE®bpÊal'mat' nig
karbkE®bGksare◊HBumı KW/acrk◊neday≤tKit´z¬.
ehATUrs¤BÊeTAelx
1-800-562-3022 (TRS: 711).
[Chinese] 免费提供语言协助服务，包括口译员和印制
资料翻译。请致电 1-800-562-3022 (TRS: 711)。
[Korean] 통역 서비스와 인쇄 자료 번역을 포함한 언어
지원 서비스를 무료로 이용하실 수 있습니다.
1-800-562-3022 (TRS: 711)번으로 전화하십시오.
[Laotian]
kanbMrikand™anfaSa, lvmtzgnaYEpfaSa ElA
kanEpewk San†Ifim, mIRv™VH™FrIodYbB˚id˚Æa. otHaelk
1-800-
562-3022 (TRS: 711).
[Oromo] Tajajilli gargaarsa afaanii, nama afaan hiikuu
fi ragaalee maxxanfaman hiikuun, kaffaltii malee ni
argattu. 1-800-562-3022 (TRS: 711) irratti bilbilaa.
[Persian] و دﺎﻧﺳا ﮫﻣﺟرﺗ و ﯽھﺎﻔﺷ مﺟرﺗﻣ ﮫﻠﻣﺟ زا ،ﯽﻧﺎﺑز ﮏﻣﮐ تﺎﻣدﺧ
هرﺎﻣﺷ ﺎﺑ.دﺷ دھاوﺧ ﮫﺋارا نﺎﮕﯾار تروﺻﺑ ،ﯽﭘﺎﭼ (بﻟﺎطﻣ) کرادﻣ
1-800-562-3022 (TRS: 711) .دﯾرﯾﮕﺑ سﺎﻣﺗ
[Punjabi]
— 
   — 
1-800-562-3022
(TRS: 711)
'
[Romanian] Serviciile de asistență lingvistică, inclusiv
cele de interpretariat și de traducere a materialelor
imprimate, sunt disponibile gratuit. Apelați 1-800-562-
3022 (TRS: 711).
[Russian] Языковая поддержка, в том числе услуги
переводчиков и перевод печатных материалов,
доступна бесплатно. Позвоните по номеру
1-800-562-3022 (TRS: 711).
[Somali] Adeego caawimaad luuqada ah, ay ku jirto
turjubaano afka ah iyo turjumid lagu sameeyo
waraaqaha la daabaco, ayaa lagu helayaa lacag
la’aan. Wac 1-800-562-3022 (TRS: 711).
[Spanish] Hay servicios de asistencia con idiomas,
incluyendo intérpretes y traducción de materiales
impresos, disponibles sin costo. Llame al 1-800-562-
3022 (TRS: 711).
[Swahili] Huduma za msaada wa lugha, ikiwa ni
pamoja na wakalimani na tafsiri ya nyaraka
zilizochapishwa, zinapatikana bure bila ya malipo.
Piga 1-800-562-3022 (TRS: 711).
[Tagalog] Mga serbisyong tulong sa wika, kabilang
ang mga tagapagsalin at pagsasalin ng nakalimbag
na mga kagamitan, ay magagamit ng walang bayad.
Tumawag sa 1-800-562-3022 (TRS: 711).
[Tigrigna]
ተርጎምትን ናይ ዝተፅሓፉ ማተርያላት ትርጉምን ሓዊሱ ናይ
ቋንቋ ሓገዝ ግልጋሎት፤ ብዘይ ምንም ክፍሊት ይርከቡ
ብ
1-800-562-3022 (TRS: 711) ደውል
[Ukrainian] Мовна підтримка, у тому числі послуги
перекладачів та переклад друкованих матеріалів,
доступна безкоштовно. Зателефонуйте за
номером 1-800-562-3022 (TRS: 711).
[Vietnamese] Các dịch vụ trợ giúp ngôn ngữ, bao gồm
thông dịch viên và bản dịch tài liệu in, hiện có miễn
phí. Gọi 1-800-562-3022 (TRS: 711).
HCA 65-153 (3/17)
[English] Language assistance services, including
interpreters and translation of printed materials, are
available free of charge. Call 1-800-562-3022
(TRS: 711).
[Amharic]
የቋንቋ እገዛ አገልግሎት፣ አስተርጓሚ እና የሰነዶችን
ትርጉም ጨምሮ በነጻ ይገኛል
1-800-562-3022 (TRS: 711)
ይደውሉ
[Arabic] نﯾﯾروﻔﻟا نﯾﻣﺟرﺗﻣﻟا كﻟذ ﻲﻓ ﺎﻣﺑ ،تﺎﻐﻠﻟا ﻲﻓ ةدﻋﺎﺳﻣﻟا تﺎﻣدﺧ
مﻗر ﻰﻠﻋ لﺻﺗا ،
ً
ﺎﻧﺎﺟﻣ ةرﻓوﺗﻣ ،ﺔﻋوﺑطﻣﻟا داوﻣﻟا ﺔﻣﺟرﺗو
3022-562-800-1 )TRS: 711.(
[Burmese]
ဘာသာျပန္ဆိုသူမ်ားႏွင့္ ထုတ္ျပန္ထားသည့္
စာရြက္စာတမ္းမ်ားဘာသာျပန္ျခင္းအပါအဝင္
ဘာသာစကားအေထာက္အကူဝန္ေဆာင္မႈမ်ားကို အခမဲ့ရႏိုင္ပါသည္။
1-800-562-3022 (TRS: 711) ကိုဖုန္းေခၚဆိုပါ။
[Cambodian] esvaCMnYyPasa rYmmanTaMg/ñkbkE®bpÊal'mat' nig
karbkE®bGksare◊HBumı KW/acrk◊neday≤tKit´z¬.
ehATUrs¤BÊeTAelx
1-800-562-3022 (TRS: 711).
[Chinese] 免费提供语言协助服务，包括口译员和印制
资料翻译。请致电 1-800-562-3022 (TRS: 711)。
[Korean] 통역 서비스와 인쇄 자료 번역을 포함한 언어
지원 서비스를 무료로 이용하실 수 있습니다.
1-800-562-3022 (TRS: 711)번으로 전화하십시오.
[Laotian]
kanbMrikand™anfaSa, lvmtzgnaYEpfaSa ElA
kanEpewk San†Ifim, mIRv™VH™FrIodYbB˚id˚Æa. otHaelk
1-800-
562-3022 (TRS: 711).
[Oromo] Tajajilli gargaarsa afaanii, nama afaan hiikuu
fi ragaalee maxxanfaman hiikuun, kaffaltii malee ni
argattu. 1-800-562-3022 (TRS: 711) irratti bilbilaa.
[Persian] و دﺎﻧﺳا ﮫﻣﺟرﺗ و ﯽھﺎﻔﺷ مﺟرﺗﻣ ﮫﻠﻣﺟ زا ،ﯽﻧﺎﺑز ﮏﻣﮐ تﺎﻣدﺧ
هرﺎﻣﺷ ﺎﺑ.دﺷ دھاوﺧ ﮫﺋارا نﺎﮕﯾار تروﺻﺑ ،ﯽﭘﺎﭼ (بﻟﺎطﻣ) کرادﻣ
1-800-562-3022 (TRS: 711) .دﯾرﯾﮕﺑ سﺎﻣﺗ
[Punjabi]
— 
   — 
1-800-562-3022
(TRS: 711)
'
[Romanian] Serviciile de asistență lingvistică, inclusiv
cele de interpretariat și de traducere a materialelor
imprimate, sunt disponibile gratuit. Apelați 1-800-562-
3022 (TRS: 711).
[Russian] Языковая поддержка, в том числе услуги
переводчиков и перевод печатных материалов,
доступна бесплатно. Позвоните по номеру
1-800-562-3022 (TRS: 711).
[Somali] Adeego caawimaad luuqada ah, ay ku jirto
turjubaano afka ah iyo turjumid lagu sameeyo
waraaqaha la daabaco, ayaa lagu helayaa lacag
la’aan. Wac 1-800-562-3022 (TRS: 711).
[Spanish] Hay servicios de asistencia con idiomas,
incluyendo intérpretes y traducción de materiales
impresos, disponibles sin costo. Llame al 1-800-562-
3022 (TRS: 711).
[Swahili] Huduma za msaada wa lugha, ikiwa ni
pamoja na wakalimani na tafsiri ya nyaraka
zilizochapishwa, zinapatikana bure bila ya malipo.
Piga 1-800-562-3022 (TRS: 711).
[Tagalog] Mga serbisyong tulong sa wika, kabilang
ang mga tagapagsalin at pagsasalin ng nakalimbag
na mga kagamitan, ay magagamit ng walang bayad.
Tumawag sa 1-800-562-3022 (TRS: 711).
[Tigrigna]
ተርጎምትን ናይ ዝተፅሓፉ ማተርያላት ትርጉምን ሓዊሱ ናይ
ቋንቋ ሓገዝ ግልጋሎት፤ ብዘይ ምንም ክፍሊት ይርከቡ
ብ
1-800-562-3022 (TRS: 711) ደውል
[Ukrainian] Мовна підтримка, у тому числі послуги
перекладачів та переклад друкованих матеріалів,
доступна безкоштовно. Зателефонуйте за
номером 1-800-562-3022 (TRS: 711).
[Vietnamese] Các dịch vụ trợ giúp ngôn ngữ, bao gồm
thông dịch viên và bản dịch tài liệu in, hiện có miễn
phí. Gọi 1-800-562-3022 (TRS: 711).
HCA 65-153 (3/17)
[English] Language assistance services, including
interpreters and translation of printed materials, are
available free of charge. Call 1-800-562-3022
(TRS: 711).
[Amharic]
የቋንቋ እገዛ አገልግሎት፣ አስተርጓሚ እና የሰነዶችን
ትርጉም ጨምሮ በነጻ ይገኛል
1-800-562-3022 (TRS: 711)
ይደውሉ
[Arabic] نﯾﯾروﻔﻟا نﯾﻣﺟرﺗﻣﻟا كﻟذ ﻲﻓ ﺎﻣﺑ ،تﺎﻐﻠﻟا ﻲﻓ ةدﻋﺎﺳﻣﻟا تﺎﻣدﺧ
مﻗر ﻰﻠﻋ لﺻﺗا ،
ً
ﺎﻧﺎﺟﻣ ةرﻓوﺗﻣ ،ﺔﻋوﺑطﻣﻟا داوﻣﻟا ﺔﻣﺟرﺗو
3022-562-800-1 )TRS: 711.(
[Burmese]
ဘာသာျပန္ဆိုသူမ်ားႏွင့္ ထုတ္ျပန္ထားသည့္
စာရြက္စာတမ္းမ်ားဘာသာျပန္ျခင္းအပါအဝင္
ဘာသာစကားအေထာက္အကူဝန္ေဆာင္မႈမ်ားကို အခမဲ့ရႏိုင္ပါသည္။
1-800-562-3022 (TRS: 711) ကိုဖုန္းေခၚဆိုပါ။
[Cambodian] esvaCMnYyPasa rYmmanTaMg/ñkbkE®bpÊal'mat' nig
karbkE®bGksare◊HBumı KW/acrk◊neday≤tKit´z¬.
ehATUrs¤BÊeTAelx
1-800-562-3022 (TRS: 711).
[Chinese] 免费提供语言协助服务，包括口译员和印制
资料翻译。请致电 1-800-562-3022 (TRS: 711)。
[Korean] 통역 서비스와 인쇄 자료 번역을 포함한 언어
지원 서비스를 무료로 이용하실 수 있습니다.
1-800-562-3022 (TRS: 711)번으로 전화하십시오.
[Laotian]
kanbMrikand™anfaSa, lvmtzgnaYEpfaSa ElA
kanEpewk San†Ifim, mIRv™VH™FrIodYbB˚id˚Æa. otHaelk
1-800-
562-3022 (TRS: 711).
[Oromo] Tajajilli gargaarsa afaanii, nama afaan hiikuu
fi ragaalee maxxanfaman hiikuun, kaffaltii malee ni
argattu. 1-800-562-3022 (TRS: 711) irratti bilbilaa.
[Persian] و دﺎﻧﺳا ﮫﻣﺟرﺗ و ﯽھﺎﻔﺷ مﺟرﺗﻣ ﮫﻠﻣﺟ زا ،ﯽﻧﺎﺑز ﮏﻣﮐ تﺎﻣدﺧ
هرﺎﻣﺷ ﺎﺑ.دﺷ دھاوﺧ ﮫﺋارا نﺎﮕﯾار تروﺻﺑ ،ﯽﭘﺎﭼ (بﻟﺎطﻣ) کرادﻣ
1-800-562-3022 (TRS: 711) .دﯾرﯾﮕﺑ سﺎﻣﺗ
[Punjabi]
— 
   — 
1-800-562-3022
(TRS: 711)
'
[Romanian] Serviciile de asistență lingvistică, inclusiv
cele de interpretariat și de traducere a materialelor
imprimate, sunt disponibile gratuit. Apelați 1-800-562-
3022 (TRS: 711).
[Russian] Языковая поддержка, в том числе услуги
переводчиков и перевод печатных материалов,
доступна бесплатно. Позвоните по номеру
1-800-562-3022 (TRS: 711).
[Somali] Adeego caawimaad luuqada ah, ay ku jirto
turjubaano afka ah iyo turjumid lagu sameeyo
waraaqaha la daabaco, ayaa lagu helayaa lacag
la’aan. Wac 1-800-562-3022 (TRS: 711).
[Spanish] Hay servicios de asistencia con idiomas,
incluyendo intérpretes y traducción de materiales
impresos, disponibles sin costo. Llame al 1-800-562-
3022 (TRS: 711).
[Swahili] Huduma za msaada wa lugha, ikiwa ni
pamoja na wakalimani na tafsiri ya nyaraka
zilizochapishwa, zinapatikana bure bila ya malipo.
Piga 1-800-562-3022 (TRS: 711).
[Tagalog] Mga serbisyong tulong sa wika, kabilang
ang mga tagapagsalin at pagsasalin ng nakalimbag
na mga kagamitan, ay magagamit ng walang bayad.
Tumawag sa 1-800-562-3022 (TRS: 711).
[Tigrigna]
ተርጎምትን ናይ ዝተፅሓፉ ማተርያላት ትርጉምን ሓዊሱ ናይ
ቋንቋ ሓገዝ ግልጋሎት፤ ብዘይ ምንም ክፍሊት ይርከቡ
ብ
1-800-562-3022 (TRS: 711) ደውል
[Ukrainian] Мовна підтримка, у тому числі послуги
перекладачів та переклад друкованих матеріалів,
доступна безкоштовно. Зателефонуйте за
номером 1-800-562-3022 (TRS: 711).
[Vietnamese] Các dịch vụ trợ giúp ngôn ngữ, bao gồm
thông dịch viên và bản dịch tài liệu in, hiện có miễn
phí. Gọi 1-800-562-3022 (TRS: 711).
HCA 65-153 (3/17)
[English] Language assistance services, including
interpreters and translation of printed materials, are
available free of charge. Call 1-800-562-3022
(TRS: 711).
[Amharic]
የቋንቋ እገዛ አገልግሎት፣ አስተርጓሚ እና የሰነዶችን
ትርጉም ጨምሮ በነጻ ይገኛል
1-800-562-3022 (TRS: 711)
ይደውሉ
[Arabic] نﯾﯾروﻔﻟا نﯾﻣﺟرﺗﻣﻟا كﻟذ ﻲﻓ ﺎﻣﺑ ،تﺎﻐﻠﻟا ﻲﻓ ةدﻋﺎﺳﻣﻟا تﺎﻣدﺧ
مﻗر ﻰﻠﻋ لﺻﺗا ،
ً
ﺎﻧﺎﺟﻣ ةرﻓوﺗﻣ ،ﺔﻋوﺑطﻣﻟا داوﻣﻟا ﺔﻣﺟرﺗو
3022-562-800-1 )TRS: 711.(
[Burmese]
ဘာသာျပန္ဆိုသူမ်ားႏွင့္ ထုတ္ျပန္ထားသည့္
စာရြက္စာတမ္းမ်ားဘာသာျပန္ျခင္းအပါအဝင္
ဘာသာစကားအေထာက္အကူဝန္ေဆာင္မႈမ်ားကို အခမဲ့ရႏိုင္ပါသည္။
1-800-562-3022 (TRS: 711) ကိုဖုန္းေခၚဆိုပါ။
[Cambodian] esvaCMnYyPasa rYmmanTaMg/ñkbkE®bpÊal'mat' nig
karbkE®bGksare◊HBumı KW/acrk◊neday≤tKit´z¬.
ehATUrs¤BÊeTAelx
1-800-562-3022 (TRS: 711).
[Chinese] 免费提供语言协助服务，包括口译员和印制
资料翻译。请致电 1-800-562-3022 (TRS: 711)。
[Korean] 통역 서비스와 인쇄 자료 번역을 포함한 언어
지원 서비스를 무료로 이용하실 수 있습니다.
1-800-562-3022 (TRS: 711)번으로 전화하십시오.
[Laotian]
kanbMrikand™anfaSa, lvmtzgnaYEpfaSa ElA
kanEpewk San†Ifim, mIRv™VH™FrIodYbB˚id˚Æa. otHaelk
1-800-
562-3022 (TRS: 711).
[Oromo] Tajajilli gargaarsa afaanii, nama afaan hiikuu
fi ragaalee maxxanfaman hiikuun, kaffaltii malee ni
argattu. 1-800-562-3022 (TRS: 711) irratti bilbilaa.
[Persian] و دﺎﻧﺳا ﮫﻣﺟرﺗ و ﯽھﺎﻔﺷ مﺟرﺗﻣ ﮫﻠﻣﺟ زا ،ﯽﻧﺎﺑز ﮏﻣﮐ تﺎﻣدﺧ
هرﺎﻣﺷ ﺎﺑ.دﺷ دھاوﺧ ﮫﺋارا نﺎﮕﯾار تروﺻﺑ ،ﯽﭘﺎﭼ (بﻟﺎطﻣ) کرادﻣ
1-800-562-3022 (TRS: 711) .دﯾرﯾﮕﺑ سﺎﻣﺗ
[Punjabi]
— 
   — 
1-800-562-3022
(TRS: 711)
'
[Romanian] Serviciile de asistență lingvistică, inclusiv
cele de interpretariat și de traducere a materialelor
imprimate, sunt disponibile gratuit. Apelați 1-800-562-
3022 (TRS: 711).
[Russian] Языковая поддержка, в том числе услуги
переводчиков и перевод печатных материалов,
доступна бесплатно. Позвоните по номеру
1-800-562-3022 (TRS: 711).
[Somali] Adeego caawimaad luuqada ah, ay ku jirto
turjubaano afka ah iyo turjumid lagu sameeyo
waraaqaha la daabaco, ayaa lagu helayaa lacag
la’aan. Wac 1-800-562-3022 (TRS: 711).
[Spanish] Hay servicios de asistencia con idiomas,
incluyendo intérpretes y traducción de materiales
impresos, disponibles sin costo. Llame al 1-800-562-
3022 (TRS: 711).
[Swahili] Huduma za msaada wa lugha, ikiwa ni
pamoja na wakalimani na tafsiri ya nyaraka
zilizochapishwa, zinapatikana bure bila ya malipo.
Piga 1-800-562-3022 (TRS: 711).
[Tagalog] Mga serbisyong tulong sa wika, kabilang
ang mga tagapagsalin at pagsasalin ng nakalimbag
na mga kagamitan, ay magagamit ng walang bayad.
Tumawag sa 1-800-562-3022 (TRS: 711).
[Tigrigna]
ተርጎምትን ናይ ዝተፅሓፉ ማተርያላት ትርጉምን ሓዊሱ ናይ
ቋንቋ ሓገዝ ግልጋሎት፤ ብዘይ ምንም ክፍሊት ይርከቡ
ብ
1-800-562-3022 (TRS: 711) ደውል
[Ukrainian] Мовна підтримка, у тому числі послуги
перекладачів та переклад друкованих матеріалів,
доступна безкоштовно. Зателефонуйте за
номером 1-800-562-3022 (TRS: 711).
[Vietnamese] Các dịch vụ trợ giúp ngôn ngữ, bao gồm
thông dịch viên và bản dịch tài liệu in, hiện có miễn
phí. Gọi 1-800-562-3022 (TRS: 711).
HCA 65-153 (3/17)
[English] Language assistance services, including
interpreters and translation of printed materials, are
available free of charge. Call 1-800-562-3022
(TRS: 711).
[Amharic]
የቋንቋ እገዛ አገልግሎት፣ አስተርጓሚ እና የሰነዶችን
ትርጉም ጨምሮ በነጻ ይገኛል
1-800-562-3022 (TRS: 711)
ይደውሉ
[Arabic] نﯾﯾروﻔﻟا نﯾﻣﺟرﺗﻣﻟا كﻟذ ﻲﻓ ﺎﻣﺑ ،تﺎﻐﻠﻟا ﻲﻓ ةدﻋﺎﺳﻣﻟا تﺎﻣدﺧ
مﻗر ﻰﻠﻋ لﺻﺗا ،
ً
ﺎﻧﺎﺟﻣ ةرﻓوﺗﻣ ،ﺔﻋوﺑطﻣﻟا داوﻣﻟا ﺔﻣﺟرﺗو
3022-562-800-1 )TRS: 711.(
[Burmese]
ဘာသာျပန္ဆိုသူမ်ားႏွင့္ ထုတ္ျပန္ထားသည့္
စာရြက္စာတမ္းမ်ားဘာသာျပန္ျခင္းအပါအဝင္
ဘာသာစကားအေထာက္အကူဝန္ေဆာင္မႈမ်ားကို အခမဲ့ရႏိုင္ပါသည္။
1-800-562-3022 (TRS: 711) ကိုဖုန္းေခၚဆိုပါ။
[Cambodian] esvaCMnYyPasa rYmmanTaMg/ñkbkE®bpÊal'mat' nig
karbkE®bGksare◊HBumı KW/acrk◊neday≤tKit´z¬.
ehATUrs¤BÊeTAelx
1-800-562-3022 (TRS: 711).
[Chinese] 免费提供语言协助服务，包括口译员和印制
资料翻译。请致电 1-800-562-3022 (TRS: 711)。
[Korean] 통역 서비스와 인쇄 자료 번역을 포함한 언어
지원 서비스를 무료로 이용하실 수 있습니다.
1-800-562-3022 (TRS: 711)번으로 전화하십시오.
[Laotian]
kanbMrikand™anfaSa, lvmtzgnaYEpfaSa ElA
kanEpewk San†Ifim, mIRv™VH™FrIodYbB˚id˚Æa. otHaelk
1-800-
562-3022 (TRS: 711).
[Oromo] Tajajilli gargaarsa afaanii, nama afaan hiikuu
fi ragaalee maxxanfaman hiikuun, kaffaltii malee ni
argattu. 1-800-562-3022 (TRS: 711) irratti bilbilaa.
[Persian] و دﺎﻧﺳا ﮫﻣﺟرﺗ و ﯽھﺎﻔﺷ مﺟرﺗﻣ ﮫﻠﻣﺟ زا ،ﯽﻧﺎﺑز ﮏﻣﮐ تﺎﻣدﺧ
هرﺎﻣﺷ ﺎﺑ.دﺷ دھاوﺧ ﮫﺋارا نﺎﮕﯾار تروﺻﺑ ،ﯽﭘﺎﭼ (بﻟﺎطﻣ) کرادﻣ
1-800-562-3022 (TRS: 711) .دﯾرﯾﮕﺑ سﺎﻣﺗ
[Punjabi]
— 
   — 
1-800-562-3022
(TRS: 711)
'
[Romanian] Serviciile de asistență lingvistică, inclusiv
cele de interpretariat și de traducere a materialelor
imprimate, sunt disponibile gratuit. Apelați 1-800-562-
3022 (TRS: 711).
[Russian] Языковая поддержка, в том числе услуги
переводчиков и перевод печатных материалов,
доступна бесплатно. Позвоните по номеру
1-800-562-3022 (TRS: 711).
[Somali] Adeego caawimaad luuqada ah, ay ku jirto
turjubaano afka ah iyo turjumid lagu sameeyo
waraaqaha la daabaco, ayaa lagu helayaa lacag
la’aan. Wac 1-800-562-3022 (TRS: 711).
[Spanish] Hay servicios de asistencia con idiomas,
incluyendo intérpretes y traducción de materiales
impresos, disponibles sin costo. Llame al 1-800-562-
3022 (TRS: 711).
[Swahili] Huduma za msaada wa lugha, ikiwa ni
pamoja na wakalimani na tafsiri ya nyaraka
zilizochapishwa, zinapatikana bure bila ya malipo.
Piga 1-800-562-3022 (TRS: 711).
[Tagalog] Mga serbisyong tulong sa wika, kabilang
ang mga tagapagsalin at pagsasalin ng nakalimbag
na mga kagamitan, ay magagamit ng walang bayad.
Tumawag sa 1-800-562-3022 (TRS: 711).
[Tigrigna]
ተርጎምትን ናይ ዝተፅሓፉ ማተርያላት ትርጉምን ሓዊሱ ናይ
ቋንቋ ሓገዝ ግልጋሎት፤ ብዘይ ምንም ክፍሊት ይርከቡ
ብ
1-800-562-3022 (TRS: 711) ደውል
[Ukrainian] Мовна підтримка, у тому числі послуги
перекладачів та переклад друкованих матеріалів,
доступна безкоштовно. Зателефонуйте за
номером 1-800-562-3022 (TRS: 711).
[Vietnamese] Các dịch vụ trợ giúp ngôn ngữ, bao gồm
thông dịch viên và bản dịch tài liệu in, hiện có miễn
phí. Gọi 1-800-562-3022 (TRS: 711).
HCA 65-153 (3/17)
[English] Language assistance services, including
interpreters and translation of printed materials, are
available free of charge. Call 1-800-562-3022
(TRS: 711).
[Amharic]
የቋንቋ እገዛ አገልግሎት፣ አስተርጓሚ እና የሰነዶችን
ትርጉም ጨምሮ በነጻ ይገኛል
1-800-562-3022 (TRS: 711)
ይደውሉ
[Arabic] نﯾﯾروﻔﻟا نﯾﻣﺟرﺗﻣﻟا كﻟذ ﻲﻓ ﺎﻣﺑ ،تﺎﻐﻠﻟا ﻲﻓ ةدﻋﺎﺳﻣﻟا تﺎﻣدﺧ
مﻗر ﻰﻠﻋ لﺻﺗا ،
ً
ﺎﻧﺎﺟﻣ ةرﻓوﺗﻣ ،ﺔﻋوﺑطﻣﻟا داوﻣﻟا ﺔﻣﺟرﺗو
3022-562-800-1 )TRS: 711.(
[Burmese]
ဘာသာျပန္ဆိုသူမ်ားႏွင့္ ထုတ္ျပန္ထားသည့္
စာရြက္စာတမ္းမ်ားဘာသာျပန္ျခင္းအပါအဝင္
ဘာသာစကားအေထာက္အကူဝန္ေဆာင္မႈမ်ားကို အခမဲ့ရႏိုင္ပါသည္။
1-800-562-3022 (TRS: 711) ကိုဖုန္းေခၚဆိုပါ။
[Cambodian] esvaCMnYyPasa rYmmanTaMg/ñkbkE®bpÊal'mat' nig
karbkE®bGksare◊HBumı KW/acrk◊neday≤tKit´z¬.
ehATUrs¤BÊeTAelx
1-800-562-3022 (TRS: 711).
[Chinese] 免费提供语言协助服务，包括口译员和印制
资料翻译。请致电 1-800-562-3022 (TRS: 711)。
[Korean] 통역 서비스와 인쇄 자료 번역을 포함한 언어
지원 서비스를 무료로 이용하실 수 있습니다.
1-800-562-3022 (TRS: 711)번으로 전화하십시오.
[Laotian]
kanbMrikand™anfaSa, lvmtzgnaYEpfaSa ElA
kanEpewk San†Ifim, mIRv™VH™FrIodYbB˚id˚Æa. otHaelk
1-800-
562-3022 (TRS: 711).
[Oromo] Tajajilli gargaarsa afaanii, nama afaan hiikuu
fi ragaalee maxxanfaman hiikuun, kaffaltii malee ni
argattu. 1-800-562-3022 (TRS: 711) irratti bilbilaa.
[Persian] و دﺎﻧﺳا ﮫﻣﺟرﺗ و ﯽھﺎﻔﺷ مﺟرﺗﻣ ﮫﻠﻣﺟ زا ،ﯽﻧﺎﺑز ﮏﻣﮐ تﺎﻣدﺧ
هرﺎﻣﺷ ﺎﺑ.دﺷ دھاوﺧ ﮫﺋارا نﺎﮕﯾار تروﺻﺑ ،ﯽﭘﺎﭼ (بﻟﺎطﻣ) کرادﻣ
1-800-562-3022 (TRS: 711) .دﯾرﯾﮕﺑ سﺎﻣﺗ
[Punjabi]
— 
   — 
1-800-562-3022
(TRS: 711)
'
[Romanian] Serviciile de asistență lingvistică, inclusiv
cele de interpretariat și de traducere a materialelor
imprimate, sunt disponibile gratuit. Apelați 1-800-562-
3022 (TRS: 711).
[Russian] Языковая поддержка, в том числе услуги
переводчиков и перевод печатных материалов,
доступна бесплатно. Позвоните по номеру
1-800-562-3022 (TRS: 711).
[Somali] Adeego caawimaad luuqada ah, ay ku jirto
turjubaano afka ah iyo turjumid lagu sameeyo
waraaqaha la daabaco, ayaa lagu helayaa lacag
la’aan. Wac 1-800-562-3022 (TRS: 711).
[Spanish] Hay servicios de asistencia con idiomas,
incluyendo intérpretes y traducción de materiales
impresos, disponibles sin costo. Llame al 1-800-562-
3022 (TRS: 711).
[Swahili] Huduma za msaada wa lugha, ikiwa ni
pamoja na wakalimani na tafsiri ya nyaraka
zilizochapishwa, zinapatikana bure bila ya malipo.
Piga 1-800-562-3022 (TRS: 711).
[Tagalog] Mga serbisyong tulong sa wika, kabilang
ang mga tagapagsalin at pagsasalin ng nakalimbag
na mga kagamitan, ay magagamit ng walang bayad.
Tumawag sa 1-800-562-3022 (TRS: 711).
[Tigrigna]
ተርጎምትን ናይ ዝተፅሓፉ ማተርያላት ትርጉምን ሓዊሱ ናይ
ቋንቋ ሓገዝ ግልጋሎት፤ ብዘይ ምንም ክፍሊት ይርከቡ
ብ
1-800-562-3022 (TRS: 711) ደውል
[Ukrainian] Мовна підтримка, у тому числі послуги
перекладачів та переклад друкованих матеріалів,
доступна безкоштовно. Зателефонуйте за
номером 1-800-562-3022 (TRS: 711).
[Vietnamese] Các dịch vụ trợ giúp ngôn ngữ, bao gồm
thông dịch viên và bản dịch tài liệu in, hiện có miễn
phí. Gọi 1-800-562-3022 (TRS: 711).
HCA 65-153 (3/17)
[English] Language assistance services, including
interpreters and translation of printed materials, are
available free of charge. Call 1-800-562-3022
(TRS: 711).
[Amharic]
የቋንቋ እገዛ አገልግሎት፣ አስተርጓሚ እና የሰነዶችን
ትርጉም ጨምሮ በነጻ ይገኛል
1-800-562-3022 (TRS: 711)
ይደውሉ
[Arabic] نﯾﯾروﻔﻟا نﯾﻣﺟرﺗﻣﻟا كﻟذ ﻲﻓ ﺎﻣﺑ ،تﺎﻐﻠﻟا ﻲﻓ ةدﻋﺎﺳﻣﻟا تﺎﻣدﺧ
مﻗر ﻰﻠﻋ لﺻﺗا ،
ً
ﺎﻧﺎﺟﻣ ةرﻓوﺗﻣ ،ﺔﻋوﺑطﻣﻟا داوﻣﻟا ﺔﻣﺟرﺗو
3022-562-800-1 )TRS: 711.(
[Burmese]
ဘာသာျပန္ဆိုသူမ်ားႏွင့္ ထုတ္ျပန္ထားသည့္
စာရြက္စာတမ္းမ်ားဘာသာျပန္ျခင္းအပါအဝင္
ဘာသာစကားအေထာက္အကူဝန္ေဆာင္မႈမ်ားကို အခမဲ့ရႏိုင္ပါသည္။
1-800-562-3022 (TRS: 711) ကိုဖုန္းေခၚဆိုပါ။
[Cambodian] esvaCMnYyPasa rYmmanTaMg/ñkbkE®bpÊal'mat' nig
karbkE®bGksare◊HBumı KW/acrk◊neday≤tKit´z¬.
ehATUrs¤BÊeTAelx
1-800-562-3022 (TRS: 711).
[Chinese] 免费提供语言协助服务，包括口译员和印制
资料翻译。请致电 1-800-562-3022 (TRS: 711)。
[Korean] 통역 서비스와 인쇄 자료 번역을 포함한 언어
지원 서비스를 무료로 이용하실 수 있습니다.
1-800-562-3022 (TRS: 711)번으로 전화하십시오.
[Laotian]
kanbMrikand™anfaSa, lvmtzgnaYEpfaSa ElA
kanEpewk San†Ifim, mIRv™VH™FrIodYbB˚id˚Æa. otHaelk
1-800-
562-3022 (TRS: 711).
[Oromo] Tajajilli gargaarsa afaanii, nama afaan hiikuu
fi ragaalee maxxanfaman hiikuun, kaffaltii malee ni
argattu. 1-800-562-3022 (TRS: 711) irratti bilbilaa.
[Persian] و دﺎﻧﺳا ﮫﻣﺟرﺗ و ﯽھﺎﻔﺷ مﺟرﺗﻣ ﮫﻠﻣﺟ زا ،ﯽﻧﺎﺑز ﮏﻣﮐ تﺎﻣدﺧ
هرﺎﻣﺷ ﺎﺑ.دﺷ دھاوﺧ ﮫﺋارا نﺎﮕﯾار تروﺻﺑ ،ﯽﭘﺎﭼ (بﻟﺎطﻣ) کرادﻣ
1-800-562-3022 (TRS: 711) .دﯾرﯾﮕﺑ سﺎﻣﺗ
[Punjabi]
— 
   — 
1-800-562-3022
(TRS: 711)
'
[Romanian] Serviciile de asistență lingvistică, inclusiv
cele de interpretariat și de traducere a materialelor
imprimate, sunt disponibile gratuit. Apelați 1-800-562-
3022 (TRS: 711).
[Russian] Языковая поддержка, в том числе услуги
переводчиков и перевод печатных материалов,
доступна бесплатно. Позвоните по номеру
1-800-562-3022 (TRS: 711).
[Somali] Adeego caawimaad luuqada ah, ay ku jirto
turjubaano afka ah iyo turjumid lagu sameeyo
waraaqaha la daabaco, ayaa lagu helayaa lacag
la’aan. Wac 1-800-562-3022 (TRS: 711).
[Spanish] Hay servicios de asistencia con idiomas,
incluyendo intérpretes y traducción de materiales
impresos, disponibles sin costo. Llame al 1-800-562-
3022 (TRS: 711).
[Swahili] Huduma za msaada wa lugha, ikiwa ni
pamoja na wakalimani na tafsiri ya nyaraka
zilizochapishwa, zinapatikana bure bila ya malipo.
Piga 1-800-562-3022 (TRS: 711).
[Tagalog] Mga serbisyong tulong sa wika, kabilang
ang mga tagapagsalin at pagsasalin ng nakalimbag
na mga kagamitan, ay magagamit ng walang bayad.
Tumawag sa 1-800-562-3022 (TRS: 711).
[Tigrigna]
ተርጎምትን ናይ ዝተፅሓፉ ማተርያላት ትርጉምን ሓዊሱ ናይ
ቋንቋ ሓገዝ ግልጋሎት፤ ብዘይ ምንም ክፍሊት ይርከቡ
ብ
1-800-562-3022 (TRS: 711) ደውል
[Ukrainian] Мовна підтримка, у тому числі послуги
перекладачів та переклад друкованих матеріалів,
доступна безкоштовно. Зателефонуйте за
номером 1-800-562-3022 (TRS: 711).
[Vietnamese] Các dịch vụ trợ giúp ngôn ngữ, bao gồm
thông dịch viên và bản dịch tài liệu in, hiện có miễn
phí. Gọi 1-800-562-3022 (TRS: 711).
Page 8 of 18
Washington Apple Health Application
for Aged, Blind, Disabled/Long-Term Services and Supports

  
 e

 e


 e




 de
HCA 18-005 (1/23)

2 

In-Home Caregiver Services
Assisted Living/Adult Family Home
Nursing Home Care
Tailored Supports for Older Adults (TSOA)
Health Care Coverage for Aged, Blind, or Disabled
Medicare Savings Program
Apple Health for Workers with Disabilities (HWD)
3 
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? Yes No If yes, list who:
4 
Will you or anyone you’re applying for need an interpreter or to receive documents in another language? Yes No
If yes, what language or alternative format do you need? List all that apply:
5 


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? Yes No
Citizen or Non-citizen status: 
U.S. citizen Yes No Washington resident Yes No

Cuban Mexican/Mexican-American/Chicano Not Spanish/Hispanic
Other Spanish/Hispanic Puerto Rican
Race (OPTIONAL – select up to ve that apply)
American Indian or Alaska Native Chinese Korean Thai
Asian Filipino Laotian Vietnamese
Asian Indian Guamanian Other Pacic Islander White
SELF

Black or African American Hawaiian Other Race
Cambodian Japanese Samoan
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? Yes No
Citizen or Non-citizen status: 
U.S. citizen Yes No Washington resident Yes No

Cuban Mexican/Mexican-American/Chicano Not Spanish/Hispanic
Other Spanish/Hispanic Puerto Rican
Race (OPTIONAL – select up to ve that apply)
American Indian or Alaska Native Chinese Korean Thai
Asian Filipino Laotian Vietnamese
Asian Indian Guamanian Other Pacic Islander White
Black or African American Hawaiian Other Race
Cambodian Japanese Samoan
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? Yes No
Citizen or Non-citizen status: 
U.S. citizen Yes No Washington resident Yes No

Cuban Mexican/Mexican-American/Chicano Not Spanish/Hispanic
Other Spanish/Hispanic Puerto Rican
Page 11 of 18
Race (OPTIONAL – select up to ve that apply)
American Indian or Alaska Native Chinese Korean Thai
Asian Filipino Laotian Vietnamese
Asian Indian Guamanian Other Pacic Islander White
Black or African American Hawaiian Other Race
Cambodian Japanese Samoan
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? Yes No
Citizen or Non-citizen status: 
U.S. citizen Yes No Washington resident Yes No

Cuban Mexican/Mexican-American/Chicano Not Spanish/Hispanic
Other Spanish/Hispanic Puerto Rican
Race (OPTIONAL – select up to ve that apply)
American Indian or Alaska Native Chinese Korean Thai
Asian Filipino Laotian Vietnamese
Asian Indian Guamanian Other Pacic Islander White
Black or African American Hawaiian Other Race
Cambodian Japanese Samoan
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? Yes No
Citizen or Non-citizen status: 
U.S. citizen Yes No Washington resident Yes No

Cuban Mexican/Mexican-American/Chicano Not Spanish/Hispanic
Other Spanish/Hispanic Puerto Rican

Race (OPTIONAL – select up to ve that apply)
American Indian or Alaska Native Chinese Korean Thai
Asian Filipino Laotian Vietnamese
Asian Indian Guamanian Other Pacic Islander White
Black or African American Hawaiian Other Race
Cambodian Japanese Samoan


6 
1. In the past 30 days, I, my spouse, or someone in my household received health care coverage from another
state, tribe or other source?
Yes No If yes, explain
2. I, my spouse, or someone in my household received Supplemental Security Income (SSI) in another state?
Yes No If yes, who?
3. I, my spouse, or someone in my household is a sponsored immigrant?
Yes No If yes, who?
4. I, my spouse, or someone in my household has served in the U.S. Armed Forces, National Guard
or Reserves or been a dependent or spouse of someone who has served:
Yes No If yes, who?
5. I have a tax dependent I have not yet included on my application who does not live with me?
Yes No If yes, list tax dependent’s name(s)
6. I am: Single Married living with spouse Married living apart from spouse Divorced Widowed
In a registered Domestic Partnership Legally separated
7 
Earned income is money made from employment or self-employment, some examples* include

• 


• 
• 
• 


• 

• 
• 
• 

• 

• 

• 
• 
• 

• 


irs.gov/credits-deductions/individuals/earned-income-tax-credit/earned-income-and-earned-income-tax-
credit-eitc-tables
 I, my spouse, or someone I am applying for has income from work Yes No If yes, please complete this section.

Who earns this income: Employer’s name Employer’s phone number
 Yes No
Start date
Gross amount received (Dollar amount before deductions) every: Hour Week Two weeks
Twice a month Month
Hours per week Pay dates (e.g. 1st and 15th, or every Friday)

Who earns this income: Employer’s name Employer’s phone
 Yes No
Start date
Gross amount received (Dollar amount before deductions) every: Hour Week Two weeks
Twice a month Month
8

 Examples of other income are:
• 

• 


• 
• 
• 
• 
• 
• 
• 
• 
• 
• 

• 
• 
• 
• 

• 
 List other income you, your spouse, or anyone you are applying for receives:
Other income type
Who gets the income Gross monthly amount Who gets the income
Gross monthly amount
Other income type
Who gets the income Gross monthly amount Who gets the income
Gross monthly amount
Other income type
Who gets the income Gross monthly amount Who gets the income
Gross monthly amount
Other income type
Who gets the income Gross monthly amount Who gets the income
Gross monthly amount
Other income type
Who gets the income Gross monthly amount Who gets the income
Gross monthly amount

I, my spouse, or someone in my household receives income from an annuity investment? Yes No
Who owns the annuity Company or institution
Amount or value Monthly income Date purchased
Who owns the annuity Company or institution
Amount or value Monthly income Date purchased
9 
Rent Mortgage Space rent Homeowners ins. Property taxes Other expenses
Do you receive help from another person or agency, such as subsidized housing that pays all or part of these expenses?
Yes No If yes, who?
 
1. I, my spouse, or someone I am applying for pays or is supposed to pay:
Child or adult dependent care Monthly amount Who pays
Court ordered child support Monthly amount Who pays
Payee fees Monthly amount Who pays
Guardianship fees Monthly amount Who pays
Court ordered attorney fees Monthly amount Who pays
Recurring medical expenses Monthly amount Who pays
(include Medicare or other health
insurance premiums you pay)
2. I, my spouse, or someone I am applying for owes medical expenses?
Medical expense type Date incurred Amount owed Who owes
Medical expense type Date incurred Amount owed Who owes
Medical expense type Date incurred Amount owed Who owes

 I, my spouse, or someone I am applying for has a disability and is working and has expenses that support
employment? These are called Impairment Related Work Expenses (IRWE):
Yes No If yes, give IRWE amount
 
(Skip this section if only applying for Medicare Savings Programs (MSP) or Apple Health for Workers with Disabilities (HWD))
1. A resource is anything you own or are buying that can be sold, traded, or converted into cash or money held by others. A
resource does not include personal property such as furniture, household goods, or clothing. Examples of resources are:
• 
• 
• 
• 
• 
• 
• 
• 
• 
• 
• 
• 
• 
• 
• 

• 
• 
• 
• 
• 
• 
• 
• 
• 
• 
• 
• 
• 
2. List the resources you, your spouse, or anyone you are applying for owns or is buying:
Resource type Who owns Location Value Who owns Location Value
Resource type Who owns Location Value Who owns Location Value
Resource type Who owns Location Value Who owns Location Value
Resource type Who owns Location Value Who owns Location Value
 I, my spouse, or someone I’m applying for has cars, trucks, vans, boats, RVs, trailers, or other motor vehicles:
Year (e.g., 2010)
Make (e.g., Ford) Model (e.g., Escort) Amount owed
Check if leased Check if used for medical purposes
Year (e.g., 2010)
Make (e.g., Ford) Model (e.g., Escort) Amount owed
Check if leased Check if used for medical purposes

(Complete only if you are applying for LTSS services)
 I, my spouse, or someone I am applying for owns or is buying a home which is a primary residence:
Property address
Current value (Per assessor)
Loan amounts owed on property
Property address
Current value (Per assessor)
Loan amounts owed on property

 I, my spouse, or someone I am applying for has sold, traded, given away, or transferred a resource in the last ve years
(including property trusts, vehicles, cash, or life estates)? Yes No If yes, complete the following: (attach additional
sheets, if necessary)
Type of resource
Date of transfer
Value of resource transferred
Who was it transferred to
Type of resource
Date of transfer
Value of resource transferred
Who was it transferred to
 
I/we have long-term care insurance? Yes No Is this a qualied LTC Partnership (LTCP) policy? Yes No
If yes, please list the name(s) of the insurance company and who the policy covers:
Insurance company Policy number
Policy holder's name Covered person Dollar value (if LTCP)
Insurance company Policy number
Policy holder's name Covered person Dollar value (if LTCP)
To include any additional comments for this application, attach a sheet with the information.
 
An authorized representative is any adult who is aware of the household circumstances and is authorized by the household to
act on behalf of the household for eligibility purposes.
By designating an authorized representative, you are giving permission for your authorized representative to:
 
 
 
1. Are you designating an authorized representative? Yes No
2. Do you want your authorized representative to receive notices related to your application
and account? Yes No
3. Does this authorized representative have legal guardianship
Yes No If yes, for who:
4. Does this authorized representative have power of attorney?
Yes No If yes, for who:
Authorized representative name / organization
Phone number Email address
Mailing address of authorized representative

 

By law, the State of Washington may recover the costs it paid for certain types of medical services from your estate through
Estate Recovery (RCW 41.05A.090, RCW 43.20B.080, and Chapter 182-527 WAC). Estate Recovery doesn’t
happen until aer your death, the death of your surviving spouse, and your surviving children are age 21 or older. It also doesn’t
happen if a surviving child is blind/disabled at your time of death. Recoverable costs include:
Certain Washington Apple Health long-term services and supports, if you’re age 55 or older at the
time you received the services.
Certain state-only funded services, regardless of your age at the time you received the services.


The State may also le a pre-death lien on your real property, at any age, if you become permanently institutionalized (WAC
182-527-2734). The State may recover from a sale of the property, or your estate, unless:
 
 
 
 
You can nd a list of services subject to cost recovery under a pre-death lien in WAC 182-527-2734.

You understand that you assign third party payments for medical care to the State of Washington when you receive Washington
Apple Health coverage. This means that the State of Washington will bill any other insurance plan that is legally obligated to
cover any of your medical expenses (this could be the insurance plan of an ex-spouse or a parent that you no longer live with).
The subscriber of that insurance plan could receive information about your medical expenses that are paid by that plan. If you
are afraid that this could endanger you or your children, you can ask us not to pursue third party payments for medical care.

If you or your spouse has an interest in an annuity and you accept Washington Apple Health (Medicaid) Long-Term Care benets,
you must name the State of Washington as a remainder beneciary of the annuity.

If you disagree with a decision we have made regarding your health care coverage or long-term care services, you have the right
to appeal the decision through the administrative hearing process. You may also ask a supervisor and administrator to review
the disputed decision or action without aecting your rights to an administrative hearing.
 
I understand the information I provide to apply for or renew assistance will be subject to verication by federal and state oicials
to determine if it is correct. I authorize the Washington State Health Care Authority (HCA) and Department of Social and Health
Services (DSHS) to conduct asset verication to determine my eligibility and to verify the accuracy of my nancial information.
I understand the HCA and DSHS may investigate and contact any nancial institution as part of the asset verication process.
I understand this authorization ends when a nal adverse decision is made on my application, my eligibility for benets ends,
or if I revoke this authorization at any time by providing HCA or DSHS with written notice. Should I revoke or refuse to provide
authorization, I understand that I will not be eligible for any Washington Apple Health Aged, Blind or Disabled (SSI-Related)
Medicaid program.


Page 18 of 18
 
The Department oers voter registration services, including automatic voter registration.

 If you would like help lling out the voter registration form, we will help you. The decision whether
to seek or accept help is yours. You may ll out the voter registration form in private. If you believe that someone has interfered
with your right to register or to decline to register to vote, your right to privacy in deciding whether to register or in applying to
register to vote, or your right to choose your own political party or other political preference, you may file a complaint with the
Washington State Election Division, PO Box 40229, Olympia, WA 98504, email [email protected], or call 1-800-448-4881.
 Yes No


Unless you checked “No” above, you may be eligible for automatic voter registration. You are eligible for automatic voter
registration if you will be at least 18 years old by the next election, you are a citizen of the United States of America, and DSHS
has your name, residential and mailing address, date of birth, verication of citizenship information, and your signature
attesting to the truth of the information provided on this application.
 Yes No




 
I have read and understood the information in this application. I declare, under penalty of perjury under the laws of the State
of Washington, that the information I have given in this application, including the information concerning citizenship and
immigration status of the members applying for benets, is true, correct, and complete to the best of my knowledge.
Signature of client Phone number Date
Signature of spouse Phone number Date
Signature of parent for minor child client Phone number Date
Signature of authorized representative or helper Phone number Date