Received by: BestChance Network Breast and Cervical (BCN), Local Eligibility DHHS Form 3400 and Cancer Program 71 Worker or Division of DHHS Form 3400-A (BCCP) Central Eligibility Processing (DCEP) Processed by: DCEP Disabled Adult Children DHHS Form 3400 and 19 Local eligibility worker (DAC) DHHS Form 3400-A Disabled DHHS Form 3400 and 18 Local eligibility worker (DWW) DHHS Form 3400-A Elderly DHHS Form 3400 and 17 Local eligibility worker (EWW) DHHS Form 3400-A DHHS Form 3400 and Essential Spouse (ES) 81 Local eligibility worker DHHS Form 3400-A Family Planning (FP) 55 eligibility worker DHHS Form 3400 No application form Foster Care IV-E) 31 Local eligibility worker necessary Foster Care - Regular 60 eligibility worker DHHS Form 3400 (RFC) DHHS Form 3400 AND General Hospital (GH) 14 Local eligibility worker DHHS Form 3400-A Partners for Healthy Children (PHC) or 88 Local eligibility worker DHHS Form 3400 In Cúram - Child Parent/Caretaker Relative (PCR) or 59 Local eligibility worker DHHS Form 3400 Low Income Families (LIF) DHHS Form 3401 OR Nursing Home No SSI 10 Local eligibility worker – DHHS Form 3400 AND DHHS Form 3400-B Nursing Home for SSI No application form 54 Local eligibility worker Recipient (SSI-NH) necessary DHHS Form 3401 Income Trust Central Institutional Unit OR – 10, 15 Nursing Home & HCBS (CIU) DHHS Form 3400 AND DHHS Form 3400-B Pregnant Women and Infants (PW) or 12, 87 Local eligibility worker DHHS Form 3400 Optional Coverage for and Infants (OCWI)
Breast and Cervical Cancer Program (BCCP) 71 Received by: BestChance Network (BCN), Local Eligibility Worker or Division of Central Eligibility Processing (DCEP) Processed by: DCEP DHHS Form 3400 and DHHS Form 3400-A Disabled Adult Children (DAC) 19 Local eligibility worker DHHS Form 3400 and DHHS Form 3400-A Disabled (DWW) 18 Local eligibility worker DHHS Form 3400 and DHHS Form 3400-A Elderly (EWW) 17 Local eligibility worker DHHS Form 3400 and DHHS Form 3400-A Essential Spouse (ES) 81 Local eligibility worker DHHS Form 3400 and DHHS Form 3400-A Family Planning (FP) 55 eligibility worker DHHS Form 3400 Foster Care IV-E) 31 Local eligibility worker No application form necessary Foster Care - Regular (RFC) 60 eligibility worker DHHS Form 3400 General Hospital (GH) 14 Local eligibility worker DHHS Form 3400 AND DHHS Form 3400-A Partners for Healthy Children (PHC) or In Cúram - Child 88 Local eligibility worker DHHS Form 3400 Parent/Caretaker Relative (PCR) or Low Income Families (LIF) 59 Local eligibility worker DHHS Form 3400 Nursing Home – No SSI 10 Local eligibility worker DHHS Form 3401 OR DHHS Form 3400 AND DHHS Form 3400-B Nursing Home for SSI Recipient (SSI-NH) 54 Local eligibility worker No application form necessary Income Trust – Nursing Home & HCBS 10, 15 Central Institutional Unit (CIU) DHHS Form 3401 OR DHHS Form 3400 AND DHHS Form 3400-B Pregnant Women and Infants (PW) or Optional Coverage for and Infants (OCWI) 12, 87 Local eligibility worker DHHS Form 3400