DSHS 14-078: Washington Eligibility Review

DSHS 14-078 PDF Details

To start the process now, the review must have your name, address, and signature or the signature of your authorized representative. You can file it now even if it only contains these three items.

Healthcare coverage: this Eligibility Review form can only be used to renew coverage for the Washington Apple Health programs listed on this form.

Food assistance: if you need food assistance right away, fill in Questions 1 through 14 and take this form to your local office.

Local office or fax: you can take your review to a local office or fax to 1-888-338-7410.

Signing: for food assistance, both the applicant and authorized representative must sign unless there is a current authorized representative document on file.