Transcription of Application for MaineCare Benefits
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Application for MaineCare Benefits
Application for MaineCare Benefits APP10 (R06/18) Do you want help filling out this Application ? Do you have questions? Call us at 1-855-797-4357 or visit your local Department of Health and Human Services (DHHS) office. We can help! How do I apply? Fill out this Application by answering as many questions as you can. The date we get this information will establish a start date for Benefits and begin your Application . You may keep this page of the Application for your information. Apply faster online. Visit to apply online. Save your confirmation number! Who can complete the Application ? The Application should be filled out by you or an adult member of your household, or a relative, friend or authorized representative who knows the financial situation of all household members. If you would like to appoint an authorized representative to act on behalf of the household, you may do so by filling out an Appointment of Representative form. What other information may I need?
only need to fill out this application for yourself and need not include other household members. If you need Long Term Care benefits, like nursing facility care, residential care, nursing care services at home, or waiver services such as adults with brain injuries, you do not need this application. You will need a Long Term
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