State of Connecticut Department of Social Services

Application for Medicare Savings Programs (QMB, SLMB, ALMB)

W-1QMB Use this form to apply for Medicare Savings Program benefits. If you currently receive these
(Rev 8/16) benefits, please renew using the Renewal Form for Medicare Savings Programs (W-1QMBR).

Do you need a reasonable accommodation or special help to complete your application because you have a
disability? Yes No If yes, complete the next question and see page 3 about how we can help.
If you need a reasonable accommodation or special help, tell us what kind of help you need:

Tell us about yourself

Name (first, middle, last) Sex (M or F) Social Security # Date of Birth

Home Street Address City State Zip Code

Mailing Address (if different) City State Zip Code

Best phone # to reach you Marital Status (check one):

Never Married Married Separated Divorced Widowed
This application is for (check one): Spouse’s Name (first, middle, last)
Yourself only
Spouse’s Social Security # Spouse’s Date of Birth
Yourself and your spouse

Title VI of the Civil Rights Act of 1964 allows us to ask for race and ethnic origin information. You do not have to
give it to us. The information helps to make sure that we are following federal civil rights law. If you do not want
to give us this information, it will not affect your application.

Are you of Hispanic, Latino/a, or Spanish origin? No Yes (if yes, check all that apply)
Mexican, Mexican-American or Chicano/a Cuban Puerto Rican Other Hispanic, Latino/a or Spanish
Racial Heritage (check all that apply): White Black or African American American Indian or Alaska Native
Asian Indian Chinese Filipino Japanese Korean Vietnamese Other Asian
Native Hawaiian Samoan Guamanian or Chamorro Other Pacific Islander

Tell us about your citizenship status

Are you a If no, what is your What is your What is your What are the date What is your
U.S. non-citizen status? alien country of and place that you sponsor’s
citizen? (refugee, entrant, registration origin? came into the name? (if
(check one) permanent number? country? applicable)
resident, etc.)
Yes
Yourself
No
Your Yes
Spouse No
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Return to:
PO Box 1320, Manchester, CT 06045
Tell us about your medical insurance
Check if you have Medicare Part A or Part B . Check if your spouse has Medicare Part A or Part B .
Insurance for You Insurance for Your Spouse
Medicare Claim #:_______________________________ Medicare Claim #:______________________________
Insurance other than Medicare, if any: Insurance other than Medicare, if any:
Company name: Company name: ______________________________

Policy number: ________________________________ Policy number: _______________________________

Group number: ________________________________ Group number: ______________________________

Check off all the services that are covered: Check off all the services that are covered:

Hospital Doctor/Surgical Dental Hospital Doctor/Surgical Dental

Prescription Vision/Optical Long Term Care Prescription Vision/Optical Long Term

Care
Policy start date: Stop date:
Policy start date: Stop date:
Policy premium amount: $________ per _____________
Policy premium amount: $_______ per ___________
Date you started paying this premium: _______________
Date you started paying this premium: ____________

Tell us about your income

List all income that you and your spouse receive. List the amounts of income before any deductions are made.
Examples of income are: Social Security, Supplemental Security Income (SSI), wages, pensions, disability
benefits, worker’s compensation, unemployment compensation, interest, dividends, rental property income,
alimony, and child support.

Income for Yourself Income for Your Spouse

Where does the money How How often do Where does the money How How often do
come from? much you receive it? come from? much do you receive it?
do you (hourly, weekly, you (hourly, weekly,
receive? every other week, receive? every other week,
monthly, yearly) monthly, yearly)
Wages (employer name): Wages (employer name):
$ $

Interest: Interest:
$ $

Social Security (type): Social Security type):

$ $

Pension (company name): Pension (company name):

$ $

IRA (name of bank): IRA (name of bank):

$ $

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PO Box 1320, Manchester, CT 06045
 Other (describe): Other (describe):
$ $

Important information for you to know about your application

 This application is a request for help from the Medicare Savings Programs only.
 All the information given on this form is confidential and will only be used to administer the programs and will
only be disclosed as permitted by law.
 The Social Security numbers of everyone receiving or requesting assistance will be used to verify identity and
eligibility. Social Security numbers will be checked against government databases, as permitted by law.
 Information provided on this form may be verified to the extent permitted by law, including by checking
government computer databases or directly with third parties such as employers or banks.

If you need a reasonable accommodation or special help

If you cannot do something we ask you to do because you have a disability, you may request a reasonable
accommodation or special help. For example, we may be able to complete your application over the telephone if
you cannot come into the office, help you get certain proofs, or give you extra time to provide information. Contact
DSS at 1-855-626-6632 to request a reasonable accommodation or special help. If we do not agree to give you a
reasonable accommodation or special help based on your disability, you can complain to the department’s
Americans with Disabilities Act (ADA) coordinator. See the Non-Discrimination Statement on page 4.

Please read carefully and sign below

 I give permission to DSS, or any health insurer, provider, or any other entity providing services to me or my
family under the Medicaid program, to release information about me or my family as necessary for the
delivery of Medicaid program services and the administration of the Medicaid program, as permissible by
federal or state law.
 I certify under penalty of perjury that all the statements made on this form are true and complete to the best
of my knowledge. I understand that I can be criminally or civilly prosecuted under state or federal law if I
knowingly give incorrect information or fail to report something I should report.

Any person who helped you complete this form or completed this form for you must also sign.
Applicant’s Signature Date Spouse’s Signature Date

Helper or Representative’s Signature Date Relationship To Applicant

Permission to Share Information

To permit the Department of Social Services to share information about your application, please identify the
authorized individuals, agencies, or institutions that DSS may communicate with, and sign in the box.
Name: Phone #

1 Address:

Name: Phone #

2 Address:

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PO Box 1320, Manchester, CT 06045
Applicant’s Signature or Signature of Authorized Representative Date

NON-DISCRIMINATION STATEMENT
You may file discrimination complaints or request
reasonable accommodations as follows:
Commissioner of Social Services
You have the right to make a discrimination complaint
Attn: Affirmative Action Division Director/ADA
if you think we have taken action against you because
Coordinator
of your race, color, religion, sex, gender identity or
55 Farmington Avenue, Hartford, CT 06105
expression, marital status, age, national origin,
Ph: 1-860-424-5040 Toll free: 1-800-842-1508
ancestry, political beliefs, sexual orientation,
TDD: 1-800-842-4524 Fax: 1-860-424-4948
intellectual disability, mental disability, learning
disability, or physical disability, including, but not
Connecticut Commission on Human Rights and
limited to, blindness.
Opportunities
25 Sigourney Street, Hartford, CT 06106
An individual with a disability may request and receive
Ph: 1-860-541-3400 Toll free: 1-800-477-5737
a reasonable accommodation or special help from the
TDD: 1-860-541-3459 Fax: 1-860-246-5265
Department of Social Services when it is necessary to
Web: http://www.ct.gov/chro/site/default.asp
allow the individual to have an equal and meaningful
opportunity to participate in programs administered by
U.S. Dept. of Health and Human Services Office for
the Department.
Civil Rights
JFK Federal Building, Room 1875, Boston, MA 02203
If you asked for an accommodation or special help and
Ph: 1-617-565-1340 Toll free: 1-800-368-1019
we refused to provide it, you may make a complaint to
TDD: 1-800-537-7697 Fax: 1-617-565-3809
the Department’s Affirmative Action Division Director or
Web: http://www.hhs.gov/ocr/office/file/index.html
any of the agencies listed:

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PO Box 1320, Manchester, CT 06045
Persons who are deaf or hard of hearing and have a TTD/TTY device can contact DSS at 1-800-842-4524. Persons who are blind or
visually impaired can contact DSS at 1-860-424-5040.

DO YOU WANT TO REGISTER TO VOTE?

ED-682
(Rev. 9/15)

Federal and state laws require the Department of Social Services (DSS) to give you the chance to
register to vote. Please answer the questions below and print and sign your name in the space
provided.
 Are you registered to vote? Yes, I am already registered No
 If you are not registered to vote where you live now, would you like to apply to register to vote
here today? Yes No
IF YOU DO NOT CHECK EITHER BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO
REGISTER TO VOTE AT THIS TIME.

Applying to register or declining to register to vote will not affect the amount of assistance that you
will be provided by this agency.
If you would like help in filling out the voter registration application form, we will help you. The
decision whether to seek or accept help is yours. You may fill out the application form in private.

You can register online at https://voterregistration.ct.gov/OLVR, or you can complete a paper voter
registration application form and leave it at DSS or mail it in. The form is included with DSS
applications and renewals that we mail to you, and you can also get one at all DSS offices. You can
mail your completed form to DSS in the enclosed envelope or send it directly to your Town Hall. If you
need help, please call 1-855-626-6632.

Print Your Name Sign Here Date

Your Address (#, Street, Apt #) City State Zip Code

For Worker’s Use Only

Date ____________________ No boxes checked Voter Registration Card Sent

Worker Name ___________________________ Worker Number __________________________

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(Tear Here and Keep)

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
you own political party or other political preferences, you may file a complaint with: State Elections
Enforcement Commission, 20 Trinity Street, Hartford, CT 06106; 860-256-2940, toll-free 866-733-2463,
TDD: 1-800-842-9710; SEEC@ct.gov