Are you a Healthy Connections Medicaid member who has recently moved? We have an easy way for you to update your address! Visit apply.scdhhs.gov to find our change of address portal. We always need your current information so we can send you any updates about your Medicaid coverage.
Now you can submit requested info, report a change in income, return an annual review, or submit other documents online using SCDHHS' Document Upload tool. SCDHHS will use the info you give to match your uploaded documents with your Medicaid application, if you have one. We will also use the contact info you provide to reach out to you if we have any questions about the documents
General Application and Supporting Forms
- Healthy Connections Application (Form 3400)
- Additional Information for Select Medicaid Programs (Form 3400-A)
- Additional Information for Nursing Home and In-Home Care (Form 3400-B)
- Additional Person in Household (Form 3400-01)
- American Indian or Alaska Native Family Member (Form 3400-Appendix B)
- Breast & Cervical Cancer Application Addendum (Form 913-A)
- Tuberculosis (TB) Referral (Form 3400-E)
- Request for Retroactive Medicaid Coverage (Form 3400-C)
Specialty Applications and Supporting Forms
- TEFRA Application (Form 3290)
- TEFRA Letter to Parent (Form 3292 ME)
- TEFRA Application Checklist (Form 923)
- Family Planning Application (Form 400)
- Single Person Household (Form 3405)
- Application for Nursing Home, Residential or In-Home Care (Form 3401)
- Income Trust Agreement (Form 905)
- Management of the Income Trust (Form 906)
- Income Trust Checklist (Form 907)
- Income Trust Schedule A (Form 3270 ME)
- Resource and Asset Statement for Community or Separated Spouse (Form 3295)
Disability Determination Forms
- Adult Disability Report (Form 3218 ME)
- Adult Disability Application Checklist (Form 3218-G ME)
- Substantial Gainful Activity Questionnaire (Form 3218-E ME)
- Child Under Age 19 Disability Report (Form 3218-D ME)
- Childhood Disability Application Checklist (Form 3218-H ME)
- Adult Continuing Disability Review (Form 3266 ME)
- Child Under Age 19 Continuing Disability Review (Form 3266-D ME)
- Authorization to Disclose Health Information | Request for Medical Records (Form 921)
Miscellaneous Forms
- Authorization for Release of Information and Appointment of Authorized Representative for Medicaid Applications/ Reviews and Appeals (Form 1282)
- Revocation of Authorization to Disclose Health Information (Form HIP02)
- Request for Fair Hearing for Medicaid Applicant and Beneficiary (Form 3260 ME)
- Confidential Complaint - Reporting Fraud (Form 126)
- Request for Change of Medicaid Information (Form 910-B)
- Addendum for Medicare Savings Programs (Form 3306)
- Medical Support Referral (Form 2700)
- Revocation of Authorization to Disclose Health Information
Revocation of Authorization to Disclose Health Information Form
- For use by the Department of Public Health (Form 400 DPH)