FOR OFFICE USE ONLY

Application for Benefits DATE RECEIVED INITIALS

Check this box if you need help filling out this form. 01-08-2026 04:31 AM

SIGNATURE (REQUIRED)
1. FIRST NAME MIDDLE INITIAL LAST NAME 2. CLIENT ID NUMBER (IF KNOWN)
MIKAEL M JOHNSON;HOLLIS A
MIKAEL JOHNSON
JOHNSON
4. PRIMARY PHONE NUMBER:
3. STREET ADDRESS WHERE YOU LIVE CITY STATE ZIP CODE
206-367-0558 (HOME)
Attn: MIKAEL M JOHNSON
17016 4TH AVE NE SHORELINE WA 98155-4920
6. SECONDARY PHONE NUMBER:
5. MAILING ADDRESS (IF DIFFERENT) CITY STATE ZIP CODE
206-407-6088 (CELL)

8. I am applying for (check all that apply): 7. EMAIL ADDRESS

Cash Food MMJ1384@[Link]
Health Care Coverage (Everyone applying is
Nursing Home
65 or older, blind, or disabled)
Assisted Living Facility / Adult Family Home Medicare Savings Program
Hospice Healthcare / Workers with Disabilities (HWD)
In-Home Long Term Care Services Child Care Subsidy Programs
Tailored Supports For Older Adults (TSOA) Other

9. I or someone in my household(check for all that apply): Are in a domestic violence situation Can't work because of health
problems Have a disability Are pregnant; due date: -
10. How much money do you expect your household to get this month? $ 3967.00
11. How much money does your household have in cash and bank accounts? $ 26.00
12. How much does your household pay for rent or mortgage? $ 0.00
13. What utilities does your household pay for? Heating/cooling Telephone Other: Electricity , Water, Sewer, Garbage
14. Is anyone in your household a seasonal or migrant farm worker? YES NO
15. If applying for food assistance, how many people in your household do you buy and prepare food for? 2
FOR OFFICE USE ONLY - Household eligible for expedited service: Yes No Screener's Initials: Date:
16. I need an interpreter. I speak: or sign; translate my letters into:
17. List everyone in your household even if you are not applying for them (attach additional sheets, if necessary).
CHECK OPTIONAL FOR NON-APPLICANTS
HOW
IF YOU
IS THIS
NAME DATE OF WANT SOCIAL CHECK TRIBE NAME(For
GENDER PERSON RACE
(FIRST, MIDDLE, LAST) BIRTH BENEFITS SECURITY IF U.S. American Indian,
RELATED NUMBER CITIZEN
(SEE SAMPLES BELOW)
Alaskan Natives)
FOR THIS
TO YOU?
PERSON
MIKAEL JOHNSON M Self 08-20-1960 536-76-1384 White,
Hollis Johnson F Spouse - White,
18. My ethnic background is Hispanic or Latino: YES NO
Race and Ethnic background information is voluntary and will not affect eligibility or benefit amounts. This information is used to assure program
benefits are distributed without regard to race, color, or national origin. For Food Assistance the USDA requires us to answer for you if no
information is provided.
Race examples:
White, Black or African American, Asian, Native Hawaiian, Pacific Islander, American Indian, Alaska Native, or any combination of races.

waconnection-WEB 14-001 (REV. 04/2023) Page 1

 I. General Information
1. In the past 30 days, I got cash, food, or medical assistance from another state, tribe, or other source. YES NO
2. Someone I'm applying for lives outside Washington State: YES NO Who:
3. I or someone in my household is a sponsored alien: YES NO Who:
4. I or someone in my household age 16 or older is in (check all that apply):
High School Equivalency Program High School College Trade School Who:

5. Someone is temporarily out of my home YES NO Who:

6. I or someone in my home has served in the U.S. Armed Forces, National Guard, or Reserves or been a dependent or spouse of someone
who has served: YES NO Who: MIKAEL JOHNSON
7. I am or someone I'm applying for is fleeing from the law to avoid going to court or jail for a felony crime: YES NO
8. I am living in: My own house or apartment Group Home Other
Facility (list type): Date entered:
9. I am: Single Married Divorced Separated Widowed In a Registered Domestic Partnership
Legally Separated Married-Living Apart
10. I or someone in my home was convicted of trading Food Assistance for drugs after September 22, 1996: YES NO
11. I or someone in my home was convicted of buying or selling Food Assistance over $500 after September 22,1996: YES NO
12. I or someone in my home was convicted of trading Food Assistance for guns, ammunitions, or explosives after September 22, 1996:
YES NO
13. I or someone in my home was convicted of getting Food Assistance in more than one State after September 22, 1996: YES NO
14. I or someone in my home is: a. On Strike: YES NO b. A boarder: YES NO
II. Health Insurance Information (Not Needed for Basic Food)
I, my spouse, or someone in my household (check appropriate box):
1. Plan to enter, are in, or recently left a medical facility (such as a hospital or nursing home) YES NO
2. Do you need help with unpaid medical bills for any of the past three months? YES NO
3. Have health insurance:
NAME
INSURANCE TYPE POLICY DETAILS
(FIRST, MIDDLE, LAST)
Insurance Carrier: United Healthcare
MIKAEL JOHNSON Other Insurance Policy Holder: MIKAEL JOHNSON
Insurance Policy Number: 90423H805044000
MIKAEL JOHNSON Medicare -
Insurance Carrier: united healthcare
Hollis Johnson Other ( medicare ) Insurance Policy Holder: MIKAEL M JOHNSON
Insurance Policy Number: 90432
Hollis Johnson Medicare -

III. Resources (Provide Proof; Cash Only)

A resource is anything you own or are buying that can be sold, traded, or converted into cash or money held by others. A resource does not
include personal property such as furniture, or clothing. Examples of resources are:
• Cash • Mutual funds • Houses, including the one • Life insurance
• Checking accounts • Stocks • you live in • Burial funds, prepaid plans
• Savings accounts • Annuities • Condominium • College funds
• CDs • Trusts • Land • Time-share
• Money market account • IRA • Sales contracts • Business equipment
• Savings bonds • 401K • Building • Farm equipment
• Bonds • Retirement fund • Life estate • Livestock

1. Please list the resources you, your spouse, or anyone you are applying for owns or is buying:
RESOURCE WHO OWNS LOCATION AMOUNT

waconnection-WEB 14-001 (REV. 04/2023) Page 2

2. I, my spouse, or someone I'm applying for have cars, trucks, vans, boats, RVs, trailers, or other motor vehicles:
YEAR CHECK IF VEHICLE IS USED
MAKE (E.G., FORD) MODEL (E.G., ESCORT) CHECK IF LEASED AMOUNT OWED
(E.G., 1980) FOR MEDICAL PURPOSE
2016 Ford Focus $ 400.00

3. I, my spouse, or someone I'm applying for has sold, traded, given away, or transferred a resource in the last five years (including trusts,
vehicles or life estates): YES NO If yes, what: and when:
TRANSFERRED FROM RESOURCE TYPE TRANSFERRED TO CASH VALUE DATE TRANSFERRED

waconnection-WEB 14-001 (REV. 04/2023) Page 3

APPLICANT'S NAME SOCIAL SECURITY NUMBER CLIENT IDENTIFICATION NUMBER
MIKAEL JOHNSON 536-76-1384
IV. Annuities (Investments made by any household member to receive regular payments now or in the future.)
WHO OWNS THE ANNUITY? COMPANY OR INSTITUTION? AMOUNT OR VALUE MONTHLY INCOME DATE PURCHASED

If you, or your spouse, have an interest in an annuity and you accept Medicaid Long Term Care benefits, you must name the State of
Washington as a remainder beneficiary of the annuity.
V. Earned Income (Provide Proof)
1. I, my spouse, or someone I'm applying for had a job that ended in the past 30 days: YES NO
2. I, my spouse, or someone I'm applying for has income from work: YES NO If yes, please complete this section:
VI. Other Income (Provide Proof, Use for all household members)
TYPE OF INCOME WHO GETS THE INCOME? GROSS MONTHLY AMOUNT

waconnection-WEB 14-001 (REV. 04/2023) Page 4

 VII. Monthly Expenses
RENT MORTGAGE SPACE RENT SUBSIDIZED HOUSING
$ $ $ $
HOMEOWNER'S INSURANCE PROPERTY TAXES PROPERTY ASSESSMENTS OTHER FEES
$ $ $ $
What utilities does your household pay for separately from rent or mortgage?
Heat (Electric/Gas) Electric (Not Heat) Home/Cell Phone Water Sewer Garbage

Another person or agency, such as subsidized housing, helps me pay either all or part of these expenses: YES NO If yes:

Who What expense Amount they pay

I received a Low Income Home Energy Assistance Act (LIHEAA) payment in the past 12 months.
I, my spouse, or someone in my household pay or are supposed to pay:
Expense Type Monthly amount Who pays
Medical bills $ 150.00 MIKAEL JOHNSON
Medical bills $ 100.00 Hollis Johnson

If you do not report any of the above listed expenses, we will consider this as a statement by your household that you do not want to receive a
deduction for this expense

waconnection-WEB 14-001 (REV. 04/2023) Page 5

 VIII. Authorized Representative
An Authorized Representative is someone you allow DSHS to talk with about your benefits.
You can name someone, but you do not have to.
Do you have an Authorized Representative? YES NO

waconnection-WEB 14-001 (REV. 04/2023) Page 6

 IX. Additional Comments

waconnection-WEB 14-001 (REV. 04/2023) Page 7

 Authorization
I understand the information I provide to apply for or renew assistance will be subject to verification by federal and state officials to determine if
it is correct. I authorize the Washington State Health Care Authority (HCA) and Department of Social and Health Services (DSHS) to conduct
asset verification to determine my eligibility and to verify the accuracy of my financial information. I understand the HCA and DSHS may
investigate and contact any financial institution as part of the asset verification process. I understand this authorization ends when a final
adverse decision is made on my application, my eligibility for benefits ends, or if I revoke this authorization at any time by providing HCA or
DSHS with written notice. Should I revoke or refuse to provide authorization, I understand that I will not be eligible for any Washington Apple
Health Aged, Blind or Disabled Medicaid program.

Revocation or refusal to authorize asset verification does not impact eligibility for Tailored Supports for Older Adults (TSOA).

I authorize HCA and DSHS to conduct asset verification to determine my eligibility and to verify the accuracy of my financial information.
Yes No

Voter Registration
The Department offers voter registration services as required by the National Voter Registration Act of 1993. Applying to register or declining
to register to vote will not affect the services or amount of benefits that you may be provided by this agency. If you would like help
in filling out the voter registration form, we will help you. The decision whether to seek or accept help is yours. You may fill out the voter
registration form in private. 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 your own political party or other political
preference, you may file a complaint with: Washington State Elections Office PO Box 40229, Olympia, WA 98504-0229 (1-800-448-4881).

Do you want to register to vote or update your voter registration? Yes No

If you do not check either box, you will be considered to have decided not to register to vote at this time.
Declaration and Signatures
If applying for cash assistance, all adults (or authorized representatives) in the household must sign.
If applying for food assistance, the applicant (or authorized representative) must sign.
I understand I must:
● Give correct information and follow reporting requirements.
● Provide proof I am eligible.
● Assign certain rights to child support, to the State of Washington when I receive Temporary Assistance for Needy Families (TANF).
However, I can ask DSHS not to pursue child support if it would endanger me or my children.
● Cooperate with food assistance work requirements.

If I don't do these things, I may be denied benefits or have to pay them back.

I understand I can be criminally prosecuted if I willfully make a false statement or fail to report something I should report.

I authorize DSHS to contact other persons or agencies when necessary to help me get proof that I am eligible.

I have read or had explained to me my rights and responsibilities and received a copy of the Client Rights and Responsibilities, DSHS 14-113.
I certify or declare under penalty of perjury under the laws of the State of Washington that the information I gave in this application,
including the information concerning citizenship and alien status of the members applying for benefits, is true and correct.
APPLICANT'S SIGNATURE Date
eSigned by MIKAEL M JOHNSON 01-08-2026
OTHER ADULT APPLICANT'S SIGNATURE Date
eSigned by HOLLIS A JOHNSON 01-08-2026
HELPER OR REPRESENTATIVE'S SIGNATURE Date

WITNESS' SIGNATURE IF SIGNED WITH AN "X" Date

waconnection-WEB 14-001 (REV. 04/2023) Page 8

 CLIENT NAME (HEAD OF HOUSEHOLD)

Your Cash and Food Assistance MIKAEL JOHNSON

CLIENT ID NUMBER
Rights and Responsibilities
Your Responsibilities (You Must)
 Give us the information we need to decide if you are eligible.
 Give us proof when it is needed. We may be able to get it for you. The information that you give the
department is subject to verification by federal and state officials. Verification can include follow-up contacts
from department staff including fraud investigators.
 Information reported to the Department of Social and Health Services may affect eligibility for health care
coverage administered by the Health Care Authority and the Health Benefit Exchange.
 Report changes (e.g. address, income, etc.) as required in WAC 388-418-0005. Report them by the 10th of the
next month.
 Cooperate with the Division of Child Support (DCS) if you accept a TANF grant. You must help DCS
establish, modify, or enforce child support for the child(ren) in your care, and establish paternity (if necessary).
You may refuse to cooperate with DCS if you can show that you have a good reason to believe that
cooperating with DCS puts you, your children, or the children in your care at risk of harm from the noncustodial
parent.
 Apply for and make a reasonable effort to get potential income from other sources when you ask for or receive
cash assistance.
 Complete required reports and reviews.
 Follow work requirements for cash assistance and food assistance.
 Tell us if you want someone else to use your food assistance on your behalf.
 Cooperate with our Quality Control reviews.
 Use food assistance only to buy food for the members of your household.
 Use cash assistance only for the benefit of members of your household.
 You must provide Social Security Numbers (SSN) or immigration status only for people applying for
assistance. If you choose not to give SSNs or immigration status for non-applying household members, all
household members' income and resources must still be verified, if needed, to determine eligibility.
Your Rights (We Must)
 Accept an application with your name, address, and signature or the signature of your authorized
representative.
 Help you fill out DSHS forms.
 Process your request for food assistance within 7 days if you qualify for expedited service.
 Give you a receipt if you ask for one when you provide documents.
 Give you a written decision, in most cases, within 30 days.
 You may refuse to speak to a Fraud Early Detection (FRED) investigator from the Office of Fraud and
Accountability. You do not have to let the investigator into your home. You may ask the investigator to come
back at another time. This will not affect your eligibility for assistance.
 You may ask for an administrative hearing if you disagree with a decision the department makes on my
case. You may also ask a supervisor or administrator to review the disputed decision or action without affecting
your rights to an administrative hearing.
 We must inform you of the 60-month time limit rule under the Temporary Assistance for Needy Families
(TANF) program. This time limit does not apply to your Basic Food, or child care subsidies.
Things You Should Know About your EBT Card
 Misuse of Benefits: Food and cash benefits distributed through the EBT card will provide DSHS with a history
of transactions where you have used your benefits. The department will use transaction information in
investigations of misuse of cash assistance benefits or the exchange of food assistance benefits for cash or
other items of value (trafficking).
 EBT card replacement: We may charge for replacement EBT cards. Keep your EBT card and your personal
identification number (PIN) safe and secure.
 High Balance EBT Cards: If you do not use your benefits for months at a time or accumulate a high balance
after several months, we may contact you to review your situation or your need for benefits.

DSHS 14-113 (REV. 04/2023) YOUR CASH AND FOOD RIGHTS AND RESPONSIBILITIES PAGE 1 OF 2
 Things You Should Know (Basic Food)
 We do send information about persons applying for Basic Food to other Federal agencies to check that the
information is correct. If any information is incorrect, the persons who apply may not get Basic Food. If a person
provides information that they know is incorrect, they could be criminally prosecuted. Penalties for intentionally
breaking Basic Food rules vary from disqualification from the program, to fines, or possibly imprisonment.
 If you sell, attempt to sell, exchange or donate your food assistance for anything of value such as cash,
drugs, weapons, or anything other than food from an authorized retailer (trafficking), you may be disqualified
from receiving food assistance benefits for a minimum period of one year up to a maximum lifetime
disqualification on the first offense. This disqualification continues even if you leave the State of Washington and
apply for benefits in another state.
 If you are required to participate in Basic Food work requirements, and fail to participate, you can be
disqualified for one month and until you comply with work requirements for the first failure; three months and until
you comply for the second failure; and six months and until you comply for the third time and each time
thereafter.
 You may be removed from the Basic Food program for breaking a Basic Food program rule as described in
the Basic Food penalty warning listed on this page.
 Report household expenses if you want the department to include these costs for Basic Food. If you
don’t report and provide proof of these expenses, then you are stating you don’t want us to use these expenses
to decide if you can get more Basic Food.
Things You Should Know (Cash)
 By getting Temporary Assistance for Needy Families (TANF) you assign your child and spousal support
rights to the Division of Child Support. This means that DCS may keep support owed to you, up to the amount of
the public assistance that you received. You must tell DCS immediately if you received child support
payments or benefits for the child while on TANF.
 If you stop getting TANF you must tell DCS about any changes that affect child support, such as the child
moved or my address changed.
 If you get TANF, you may ask for extra money to help pay for temporary emergency housing costs.
In accordance with federal civil rights law and U.S. Department of Agriculture (USDA) civil rights regulations and
policies, this institution is prohibited from discriminating on the basis of race, color, national origin, sex (including
gender identity and sexual orientation), religious creed, disability, age, political beliefs, or reprisal or retaliation for
prior civil rights activity.
Program information may be made available in languages other than English. Persons with disabilities who require
alternative means of communication to obtain program information (e.g., Braille, large print, audiotape, American
Sign Language), should contact the agency (state or local) where they applied for benefits. Individuals who are
deaf, hard of hearing or have speech disabilities may contact USDA through the Federal Relay Service at
(800)877-8339.
To file a program discrimination complaint, a Complainant should complete a Form AD-3027, USDA Program
Discrimination Complaint Form which can be obtained online at:
[Link] from any USDA office, by calling (833) 620-1071,
or by writing a letter addressed to USDA. The letter must contain the complainant’s name, address, telephone
number, and a written description of the alleged discriminatory action in sufficient detail to inform the Assistant
Secretary for Civil Rights (ASCR) about the nature and date of an alleged civil rights violation. The completed
AD-3027 form or letter must be submitted to:
1. Mail: Food and Nutrition Services, USDA
1320 Braddock Place, Room 334
Alexandria VA 23314; or
2. Fax: (833) 256-1665 or (202) 690-7442; or
3. Email: FNSCIVILRIGHTSCOMPLAINT@[Link]

This institution is an equal opportunity provider.

By signing below, I am stating I have had my rights and responsibilities on receiving DSHS benefits and programs
explained to me. I understand if I refuse to sign this document it does not affect my eligibility but I am still held
responsible for program requirements and subject to program or criminal penalties that apply.
APPLICANT’S SIGNATURE DATE CO-APPLICANT’S SIGNATURE DATE
MIKAEL M JOHNSON 01/08/2026 HOLLIS A JOHNSON 01/08/2026

DSHS STAFF ACES ID: Refused to sign.

DSHS 14-113 (REV. 04/2023) YOUR CASH AND FOOD RIGHTS AND RESPONSIBILITIES PAGE 2 OF 2
 CLIENT NAME (HEAD OF HOUSEHOLD)

Your DSHS Cash or MIKAEL JOHNSON

CLIENT ID NUMBER
Food Benefits

DSHS Cash Grants

DSHS Food Benefits
TANF, Refugee Cash, ABD Cash, Diversion

Purpose Purpose
DSHS provides cash grants to low-income residents DSHS food assistance programs include:
who qualify for public assistance programs. • Basic Food.
These benefits help pay for basic living expenses • Food Assistance Program for legal
(RCW 74.04.770). immigrants (FAP).
• Washington Combined Application Project
TANF cash grants must be used only for the benefit of (WASHCAP).
children in your care. We can require proof you are
• Transitional Food Assistance (TFA).
using your TANF grant for the children’s needs (RCW
74.12.260). These programs provide assistance for low-
income people to buy food with electronic
benefits transfer (EBT) cards.
Appropriate Use
You may use your cash grant for living expenses
Appropriate Use
such as:
You, and your household, may use your food
• Shelter • Clothing benefits to buy food from a retailer authorized
• Fuel • Home maintenance by the USDA, Food and Nutrition Service
• Food • Personal hygiene (FNS).
• Transportation • Employment expenses
You may use your benefits to buy:
• Breads and cereals.
Illegal Use • Fruits and vegetables.
Under RCW 74.08.580, it’s not legal to use Electronic • Cheese, milk, and dairy products.
Benefit Transfer (EBT) cards or cash from EBT • Meats, fish, poultry, and eggs.
cards to: • Most food other than prepared hot foods.
• Gamble. Gambling includes lottery tickets, pull • Seeds and plants that produce food.
tabs, punch boards, bingo, horse racing, casino Illegal Use
games, and any game of chance found in RCW It is illegal to:
9.46, 67.16, and 67.70.
• Buy services in tattoo, body piercing, or body art • Use food benefits for anything other than to
shops. buy food for eligible household members.
• Buy cigarettes or tobacco. • Sell, or attempt to sell, your EBT card.
• Buy alcoholic items. • Exchange your benefits, or the food
• Buy goods or services in: purchased with your EBT card, for anything
o Taverns. of value (trafficking).
o Beer or wine shops unless authorized as a Examples of illegal trafficking include
SNAP or WIC retailer. exchanging food benefits for cash, drugs, or
o Nightclubs. weapons.
o Bail bond agencies. • Give your benefits to anyone who isn’t in
o Gambling establishments. your household.
o Adult entertainment venues with erotic • Use food benefits to buy non-food items.
performances. Examples include: cigarettes, tobacco, beer,
o Any place where someone under the age of 18 wine, liquor, household supplies, soap,
isn’t allowed paper products, vitamins, medicine, or pet
 For example, marijuana retailers where food.
marijuana and/or marijuana-based products • Use your food benefits to pay on credit
are sold. accounts.
YOUR DSHS CASH OR FOOD BENEFITS
DSHS 14-520 (REV. 06/2020)
 DSHS Cash Grants
DSHS Food Benefits
TANF, Refugee Cash, ABD Cash, Diversion

Penalty for Illegal Use Penalty for Illegal Use

If you use your EBT card or cash from your EBT card If you intentionally misuse your food benefits,
illegally or inappropriately, we may: you may be:
• Assign a protective payee to manage your cash • Required to repay any trafficked benefits.
grant.
• Disqualified and lose your benefits:
• Require proof you use your grant for the children in
o For at least one year.
your care.
o Up to a lifetime.
• Terminate your cash benefits.
• Pursue legal action, including criminal prosecution. o Be disqualified even if you move to
another state.
• Subject to fines.
Automated Teller machine (ATM) fees for EBT
Withdrawals • Subject to legal action, including criminal
prosecution.
When you use your EBT card to make cash
withdrawals at an ATM: DSHS will cooperate with state, local, and
federal authorities to prosecute trafficking of
• The ATM owner or bank operating the machine may
food benefits.
charge a surcharge fee.
• The department does not pay or reimburse for ATM
surcharge fees.
• You may be able to get cash back from some stores
without a fee.

By signing below, I agree that the appropriate and legal use of DSHS cash and food benefits have been explained.
I understand the proper use of benefits and the penalties for illegal use. I understand my eligibility for DSHS
benefits isn’t affected if I don’t sign this form. Anyone who fails to sign this form is still subject to program or
criminal penalties for illegal use of benefits.

I understand my EBT card provides DSHS with a history of my transactions, including where I use my card. I
understand DSHS will use this information, and my history of requests for replacement cards, to investigate
misuse of cash grants or food benefits.
APPLICANT’S SIGNATURE DATE

MIKAEL M JOHNSON 01/08/2026

Refused to sign; DSHS Staff Initial

DSHS 14-520 (REV. 06/2020)

Health Care Coverage Rights and Responsibilities
Your rights (we must) for all health DSHS and HCA:
care coverage programs • Provide free aids and services to people
Help you read and fill out all requested forms. You with disabilities so they can communicate
can contact the Department of Social and Health effectively with us, such as:
Services (DSHS) at 1-877-501-2233 for assistance. • Qualified sign language interpreters
Provide interpreter or translator services at no cost • Written information in other formats
to you and without delay when communicating with (large print, audio, accessible
DSHS or the Health Care Authority (HCA). electronic formats, other formats)

Keep your personal information private but we may • Provide free language services to people
share some information with other state and federal whose primary language is not English,
agencies, financial institutions, and HCA contractors such as:
for purposes of eligibility and enrollment. • Qualified interpreters
Give you the opportunity to appeal if you disagree • Information written in other
with a determination made by DSHS or HCA that languages
affects your eligibility for health coverage, long-term
If you need these services, contact 1-877-501-2233.
services and supports (LTSS), or a health plan. If you
ask for an appeal, your case will be reviewed. For If you believe that DSHS or HCA has failed to provide
information about appeals for DSHS programs, you these services or discriminated in another way, you can
may contact DSHS Customer Service Contact Center at file a grievance with:
1-877-501-2233 or visit your local Community Services
• DSHS
Office.
ATTN: Constituent Services
If the appeal is for a decision on Washington Apple PO Box 45131
Health coverage, which is unresolved by a case Olympia, WA 98504-5131
review, you will be scheduled an Administrative 1-800-737-0617
Hearing. Fax: 1-888-338-7410
askdshs@[Link]
Treat you fairly. Discrimination is against the law.
DSHS and HCA comply with applicable Federal civil • HCA Division of Legal Services
rights laws and do not discriminate on the basis of ATTN: Compliance Officer
race, color, national origin, age, disability, or sex. PO Box 42704
DSHS and HCA does not exclude people or treat them Olympia, WA 98504-2704
differently because of their race, color, national 1-855-682-0787
origin, age, disability, or sex. Fax: 1-360-586-9551
DSHS and HCA also comply with applicable state laws compliance@[Link]
and do not discriminate on the basis of creed, gender,
gender expression or identity, sexual orientation, You can file a grievance in person or by phone, mail,
marital status, religion, honorably discharged veteran fax, or email. If you need help filing a grievance, the
or military status, or the use of a trained dog guide or DSHS Constituent Services or HCA Division of Legal
service animal by a person with a disability. Services is available to help you.
You can also file a civil rights complaint with the U.S.
Department of Health and Human Services, Office for
Civil Rights electronically at
[Link] or by
mail or phone at:
HCA 18-011 (12/18)

1
 U.S. Department of Health and Human Services The National Voter Registration Act of 1973 requires
200 Independence Avenue SW all states to provide voter registration assistance
Room 509F, HHH Building through their public assistance offices. Applying to
Washington, D.C. 20201 register or declining to register to vote will not affect
1-800-368-1019, 800-537-7697 (TDD). the services or benefits that you will be provided by
this agency. You can register to vote at
Complaint forms are available at
[Link] or order voter registration forms
[Link]/ocr/office/file/[Link].
by calling 1-800-448-4881.
Your responsibilities (you must)
for all health care coverage programs Health Insurance Portability and Accountability Act
(HIPAA) restrictions prevent HCA and DSHS from
SSN and Immigration Status Disclosure. With some discussing the health information of you or any
exceptions, you must provide a Social Security member of your household with anyone, including
Number (SSN) or immigration document number of an authorized representative, unless that individual
yourself or anyone else in your household who has power of attorney or you have signed a consent
wants to apply for health care coverage. An SSN is form authorizing the disclosure of this information.
required to apply for health insurance premium tax This includes disclosure of mental health
credits. We use this information to determine your information, HIV, AIDS, STD test results, or
eligibility by confirming your identity, citizenship, treatment and chemical dependency services.
immigration status, date of birth, and availability of
other health care coverage. The Affordable Care Act prevents DSHS and HCA
We do not share this information with any from giving the personally identifiable information
immigration agency. (PII) of you or any member of your household to
anyone who is not authorized to receive it, and
It is possible to apply for coverage for some without your consent.
members of your household, but not others. If you
do not have an SSN or immigration document The information that you give DSHS and HCA is
number for all household members, others can still subject to verification by federal and state officials
apply for and get coverage. For example, you can for purposes of determining your eligibility for
apply for your child even if you aren’t eligible for health care coverage. Verification can include
coverage. Applying won’t affect your immigration follow-up contacts from agency staff.
status or chances of becoming a permanent HCA and DSHS are not responsible for
resident or citizen. administering your health insurance plan. Your
There are also some Washington Apple Health health insurance carrier can provide you more
programs for people who cannot show they are in information about your benefits. If you have
the country legally. But if you choose not to provide questions about the terms of your health insurance
an SSN or immigrant document number for plan, including what benefits you are eligible for,
someone in your household, we will need to follow and making a benefit claim or appealing a denial of
up with you to get information about the non- benefits, you should contact your health insurance
applicant's income. carrier.
If requested by the agency, provide any information You may apply for support enforcement
or proof needed to decide if you are eligible. services through the Division of Child Support
Things you should know (DCS). To get an application for these services,
go to [Link] or
for all health care coverage programs contact your local DCS office.
There are certain state and federal laws that
govern the operation of Washington Connection Your rights (we must) for
and state-administered application systems, your Washington Apple Health only
rights and responsibilities as someone who uses Explain to you your rights and responsibilities
them and the coverage you get from using them. By if you ask.
using these systems, you agree to comply with the
laws that apply to someone using them and the Allow you to submit a partial application that
coverage they get as a result. includes at minimum, your name, address, and
signature or the signature of the applicant’s
authorized representative.
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 The day we get a partial application is your application date, Things you should know for
which may affect when your coverage becomes effective.
Washington Apple Health only
We will not make a final decision about your coverage until
after you complete the application. By asking for and receiving Washington Apple
Allow you to submit an application or partial Health, you give the state of Washington all rights to
application using any method listed under WAC 182- any medical support and to any third party
503-0005. payments for health care.
Process your application promptly and no later than The Agency may share your child’s immunization
the timelines described in WAC 182-503-0060. history with the Child Profile Immunization Tracking
System.
Give you 10 calendar days to provide information
we need to determine eligibility. If you ask for more Information you report may be provided to DSHS to
time, we will give you more time. If you don’t give determine eligibility and monthly benefits for
us the information or ask for more time, we may programs such as health care coverage, cash
deny, close, or change your health care coverage. assistance, food assistance and child care subsidies.
By law, the State of Washington may recover the
Help you if you have trouble getting any information costs it paid for certain types of medical services
or proof needed for us to decide if you are eligible. If from your estate through Estate Recovery (RCW
we require a document that will cost you money, we 41.05A.090, RCW 43.20B.080, and Chapter 182-527
will send for it and pay the cost. WAC). Estate Recovery doesn’t happen until after
Notify you, in most cases, at least 10 days before we your death, the death of your surviving spouse, and
stop your health care coverage. your surviving children are age 21 or older. It also
doesn’t happen if a surviving child was
Give you a written decision, in most cases, within 45
blind/disabled at your time of death. Recoverable
days. Health care coverage for some disability cases
costs include:
may take up to 60 days. We give a written decision
on pregnancy medical within 15 days. • Certain Washington Apple Health long-term
services and supports, if you’re age 55 or
Allow you to refuse to speak to an investigator if we
older at the time you received the services;
audit your case. You do not have to let an
investigator into your home. You may ask the • Certain state-only funded services,
investigator to come back at another time. Such a regardless of your age at the time you
request will not affect your eligibility for health care received the services.
coverage. You can find a list of services subject to cost
recovery under WAC 182-527-2742. You can find a
Continue Washington Apple Health coverage while
list of assets excluded from recovery under WAC
we decide if you are eligible for another program per
182-527-2746.
WAC 182-504-0125.
Give you equal access services as described in WAC The State may also file a pre-death lien on your real
182-503-0120 if you are eligible. property, at any age, if you become permanently
institutionalized (WAC 182-527-2734). The State
Your responsibilities (you must) for may recover from a sale of the property, or your
Washington Apple Health only estate, unless:
Report changes as required in WAC 182-504-0105 • Your spouse lives at the property;
and WAC 182-504-0110 within 30 days of the • Your sibling lives at the property, is a co-
change. Read your approval letter to see what owner, and meets certain conditions.
changes you must report.
• Your child lives at the property, and is
Complete renewals when asked.
blind/disabled; or
Give medical providers information needed to bill us
• Your child lives at the property and is
for health care services.
younger than age 21.
Apply for Medicare if you are entitled to it.
Cooperate with Quality Assurance staff when asked. You can find a list of services subject to cost recovery
Apply for and make a reasonable effort to get under a pre-death lien in WAC 182-527-2734.
potential income from other sources when you ask You may be restricted to one health care provider,
for or receive Washington Apple Health coverage pharmacy, and/or hospital if you seek out
unnecessary health care services from providers.

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