Applications & Forms

Online Application

To apply for benefits and services online, visit My Maine Connection. Once there, you can:

  • Apply for services 
  • Complete recertifications 
  • Review case information 
  • Submit changes or 
  • View your benefit history for the past 12 months

Paper Applications

MaineCare Application (Word) 

Use this application if you would like to apply for a MaineCare program, including: 

  • State Supplement
  • Medicare Savings Program (Buy-In)
  • Family Planning Services and 
  • Prescription Help (MaineRx & Low-Cost Drugs for the Elderly)

COVID-19 Testing Application (PDF)

Use this application if you would like to apply for coverage of COVID-19 testing.

Food Supplement, TANF, or MaineCare Application (PDF) 

Use this application if you would like to apply for:

  • Food Supplement (SNAP)
  • Temporary Assistance for Needy Families (TANF) or
  • MaineCare Programs

Long Term Care Application (PDF) 

Use this application if you’d like to apply for assistance with the cost of medical services for individuals in a: 

  • Nursing facility 
  • Residential care facility or 
  • Receiving/seeking in home nursing services

Higher Opportunity for Pathways to Employment (HOPE)

Apply for the HOPE program and learn more information.

Private Health Insurance Premium (PHIP) Application (PDF) 

Use this application if you are MaineCare member seeking help paying for private health insurance premiums.

Emergency Assistance (EA) Application (PDF) 

Use this application to apply for Emergency Assistance.  Learn more about Emergency Assistance here.

Forms

 

ASPIRE/TANF Family Contract (PDF) 

Complete this form when applying for TANF or Parents as Scholars (PaS)

Authorization to Release Information (PDF)

This form allows DHHS to release or obtain a participant's medical, billing or other confidential records to or from another provider/agency.

Authorized Representative (PDF) 

To appoint an authorized representative to act on your behalf with DHHS.

Long Term Care Personal Support Services Agreement (Word) | also as PDF

MaineCare Disability Determination (PDF) 

Complete this form if you would like to request a disability determination for MaineCare services.