Applications & Forms

All Programs

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

SNAP, TANF, or MaineCare Application (PDF)

Use this application if you would like to apply for:

The Supplemental Nutrition Assistance Program (SNAP)
Temporary Assistance for Needy Families (TANF) or
MaineCare Programs

Forms

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.

MaineCare

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 Testing & Treatment for Uninsured Individuals

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

Private Health Insurance Program (PHIP) Application (PDF )

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

Forms

MaineCare Disability Determination (PDF)

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

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

SNAP

Applications

Electronically Stolen Benefits Application (Fillable PDF)

Use this application if you had SNAP benefits stolen through card skimming, card cloning, phishing, or other electronic acquisition of the EBT card number and PIN and would like to have them replaced.

Forms

Replacement

SNAP Loss and Replacement (Fillable PDF)

Use this form to report a loss of food purchased with SNAP benefits if the loss was the result of a fire, flood, power outage, appliance failure, or other household misfortune. The report must be made within 10 days of the loss. You may submit the form by uploading it to MyMaineConnection.gov, e-mailing it to Farmington.DHHS@Maine.gov, mailing it to DHHS, OFI Farmington District Office, 114 Corn Shop Ln., Farmington, ME 04938, or dropping it at your local office. You may also report the loss by e-mailing farmington.dhhs@maine.gov or calling 1 (855) 797-4357. A completed form will still be required.

ABAWD

Medical and Behavioral Health Verification Form (PDF)

Use this form to verify a medical exemption from ABAWD work requirements. Exemptions include regular participation in substance use disorder treatment, or not being medically able to work 30 or more hours per week. The form must be completed by a licensed provider.

ABAWD Volunteer Form (PDF)

Use this form to verify sufficient hours volunteering to meet the ABAWD work requirement.