Follow the steps to successfully complete your form online.

1. Click ‘Get Form’ button to access the form and open it in your preferred editor.
2. Begin with the personal information section. Enter your full name, Social Security number, and address accurately. Ensure the contact number is currently in use.
3. Indicate your marital status by checking the appropriate box, and provide your date of birth to confirm eligibility.
4. Fill in the optional section regarding sex and provide your doctor's name along with their phone number for further assistance.
5. If applicable, state the name and phone number of your Home Health or Adult Day Care agency.
6. In the Medicaid information section, provide your Medicaid number and indicate if your Medicaid application is pending.
7. Complete the financial eligibility section by providing your income and asset information, as well as combined assets with your spouse or another individual, if relevant.
8. If married, decide if you would like a spousal assessment for asset protection, checking 'Yes' or 'No' as appropriate.
9. Sign and date the form. If you are unable to sign, have a witness sign where indicated.
10. Review the completed form for accuracy and completeness before submitting. Save changes, download, print, or share the form as needed.

Take action today by filling out the CT Home Care Program For Elders Home Care Request Form online to begin receiving the support you need.