Economic Self Sufficiency Forms
If you want to apply for Food Assistance and/or Temporary Cash Assistance, in addition to Medicaid, print and fill out the ACCESS Florida Application below.
- ACCESS Florida Application:
Fill out this application if you want to apply for Food or Cash Assistance, Family related Medical assistance, Relative Caregiver, Optional State Supplementation or medical assistance for Age 65 or over, Blind or Disabled, Medicaid Waiver/Home and Community Based Services, Hospice or Nursing Home Care.
General Program Forms
- Work Calendar
- Change Report Form
- Verification of Dependent Care Expenses
- Verification of Employment/Loss of Income
- Verification of Shelter Expenses
- Financial Information Release
- Hearings Request for Public Assistance
- Child Support Cooperation Notice
- Child Support Cooperation Good Cause / Refusal to Cooperate
- Rights and Responsibilities
- Sample Fax Cover Sheet
Food Assistance Program Forms
- Authorized Representative Designation
- Food Stamp Work Registration Notice
- Verification of Dependent Care Expenses
Temporary Cash Assistance Program Forms
- School Verification
- Change Report Form
- Immunization Verification for Public Assistance Applicant
- Notice of Learnfare Requirements
- Work Activity Referral
Medicaid Program Forms
- Appointment of a Designated Representative
- Informed Consent Long Term Care Assessment
- Medical Certification for Nursing Facility
- Patient Transfer and Continuity of Care
- Designation of Resources for Burial Funds
- Designation of Beneficiary
- Verification of Dependent Care Expenses
- Assignment of Rights to Support for Institutional Care Program
- Life Insurance Verification Request
- Authorization to Disclose Information
