101-2          APPLICATION FORMS

101-2 A.      GEN 50C FORM

The Application for Services (GEN 50CApplication for Services) 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 72Eligibility Review Form) is a review application for the Alaska Temporary Assistance Program, Supplemental Nutrition Assistance Program, Adult Public Assistance, and ADLTCAged, Disabled and Long Term Care Manual Medicaid programs. It may also be accepted for MAGIModified Adjusted Gross Income Medicaid and Senior Benefits starting with the April 2020 form revision.

101-2 C.      MED 4 FORM

The MED 4Application for Adults and Children with Long Term Care Needs 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 (TEFRATax Equity and Fiscal Responsibility Act) coverage, and for children applying for or receiving SSISupplemental Security Income.

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

FFMFederally Facilitated Marketplace is an electronic MAGIModified 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

SSPSelf-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).

101-2 F.      FSP 95 FORM

SNAPSupplemental Nutrition Assistance Program Interim Report Form (FSP 95SNAP Interim Report Form) is a periodic report, completed at the midpoint of the SNAPSupplemental Nutrition Assistance Program certification period, for households approved for 12 or 24 month SNAPSupplemental Nutrition Assistance Program certification periods.