101-2           APPLICATION FORMS

101-2 A.     GEN 50C FORM

The Application for Services (GEN 50C) is an initial application for Alaska Temporary Assistance, Supplemental Nutrition Assistance Program, Adult Public Assistance, Medicaid (including Long Term Care), General Relief Assistance, and Chronic & Acute Medical Assistance.

101-2 B.     GEN 72 FORM

The Eligibility Review Form (GEN 72) is a review application for the Alaska Temporary Assistance Program, Supplemental Nutrition Assistance Program, Adult Public Assistance, and Medicaid programs (including when the Office of Children's Services renews Medicaid for children in custody). It may also be accepted for Senior Benefits starting with the April 2020 form revision.

101-2 C.     MED 4 FORM

The Med 4 application form is a Medicaid application for adults and children with long-term care needs who want to apply for nursing home, home and community-based services, disabled child living in at home (TEFRA Tax Equity and Fiscal Responsibility Act) coverage, and for children applying for or receiving SSI Supplemental Security Income.

101-2 D.     FFM (FEDERALLY FACILITATED MARKETPLACE) FORM

FFM Federally Facilitated Marketplace is an electronic MAGI Modified Adjusted Gross Income (Modified Adjusted Gross Income) based Medicaid application for adults and children submitted to the Division through Federally Facilitated Marketplace for any Medicaid category (including Long Term Care and Adult Public Assistance related Medicaid).

101-2 E.     ARIES SSP (SELF SERVICE PORTAL) FORM

SSP Self-Service Portal is an electronic application submitted through my.Alaska.gov portal for any Medicaid category (including Long Term Care and Adult Public Assistance related Medicaid).