Dma 5097: Fill out & sign online

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Click ‘Get Form’ to open the dma-5097-ia in the editor.
Begin by entering your County Case Number and District Number in the designated fields at the top of the form.
Fill in your Worker’s Name and Telephone Number, ensuring all contact information is accurate for prompt communication.
Provide your address and the date on which you are submitting this request. This helps maintain a clear record of your application timeline.
Carefully review each section that requests additional information regarding your Medicaid/Special Assistance application. Fill in any required details, such as income amounts and medical expenses, as specified.
If applicable, check off any items you cannot provide and note alternative documentation that may be accepted. This ensures that your application can still be processed efficiently.
Finally, sign and return the form to DSS or contact your Medicaid caseworker if you need assistance or more time to gather information.

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Versions	Form popularity	Fillable & printable
2023	4.4 Satisfied (49 Votes)
2019	4.2 Satisfied (43 Votes)

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