Washington Apple Health Application
for Tailored Supports for Older Adults (TSOA)
What is TSOA?
TSOA is a program that helps caregivers who are caring for a family member for free.
It also can provide some help if you do not have a family member who helps you.
Services include:
• Respite care or home delivered meals. Respite care can pay someone to give your
caregiver a break.
• Medical equipment and supplies, such as a bath bench or incontinence supplies,
like adult diapers.
• Training and education, such as Powerful Tools for Caregivers training.
• Things that can help your caregiver, like mental health counselling or massage
therapy.
• Some help with personal care needs if you do not have a family caregiver.
Who can get TSOA?
• You are age 55 or older.
• You have a family member who helps for free, but your caregiver needs help; or
• You need help and do not have a family member who helps you on a regular basis.
You can fill out this
form or apply online.
To apply online, go to www.washingtonconnection.org.
Information you
need to apply:
(If married, give us
your spouse’s
information, too.)
• Social security number
• Birthdate
• Marital status
• Immigration status
• Income
• Resource information (such as bank account balances, stocks, bonds, trusts,
retirement accounts)
Why do we ask for
so much
information?
We have to figure out whether you qualify. We keep your information private as
required by law.
I filled out my
application.
Now what?
• Make sure you sign your application.
• Mail it to:
DSHS Home and Community Services – Long Term Care Services
PO Box 45826, Olympia, WA 98504-5826; or
• Fax it to 1-855-635-8305; or
• Take it to a local Home and Community Services (HCS) office.
See http://www.altsa.dshs.wa.gov/Resources/clickmap.htm for locations; or
• Apply online at www.washingtonconnection.org
For more
information:
• Call our toll-free number at 1-855-567-0252
• Contact your local Area Agency on Aging (AAA) office and ask to speak with a
Family Caregiver specialist. Find your local AAA office here: www.waclc.org
• To locate a local HCS office see
http://www.altsa.dshs.wa.gov/Resources/clickmap.htm
• We have an Information Sheet that tells you about TSOA and other programs. TSOA
may not be right for you.
HCA 18-008 (7/20) i
Tailored Supports for Older Adults (TSOA)
Rights and Responsibilities
We have to tell you this information. Don’t skip it.
Your rights (we must):
Explain to you your rights and responsibilities
if you ask.
Help you if you have a disability. We describe this
help in a rule. See WAC 182-503-0120.
We will help you read and fill out any form if you
need help. Call your local Home & Community
Services Office. Locations are at:
http://www.altsa.dshs.wa.gov/Resources/
clickmap.htm
If you need an interpreter or translator services,
let us know. We will not charge you. We will get
one for you right away.
Keep your personal information private. We will
only share information with other state and federal
agencies to see if you are eligible and get you on
the program.
Make a decision as quickly as we can.
If we need more information, we will tell you. You
will have 10 calendar days to give us that
information. If you ask for more time, we will give
you more time. Give us the information in 10
calendar days or ask us for more time. If you do
not, you will not get TSOA.
We will help you if you have trouble getting
information we need.
Give you a written decision, in most cases, within
45 days.
You do not have to talk to an investigator if we
audit your case. You do not have to let an
investigator into your home. Not talking to an
investigator will not affect whether you get TSOA.
Give you the opportunity to appeal if you disagree with
a determination made by the Department of Social and
Health Services (DSHS) that affects your eligibility for
TSOA. By asking for an appeal, you will be scheduled an
Administrative Hearing.
Treat you fairly. Discrimination is against the law.
DSHS and the Health Care Authority (HCA) comply with
applicable federal civil rights laws and do not
discriminate on the basis of race, color, national origin,
age, disability, or sex. DSHS and HCA does not exclude
people or treat them differently because of their race,
color, national origin, age, disability, or sex.
DSHS and HCA also comply with applicable state laws and
do not discriminate on the basis of creed, gender, gender
expression or identity, sexual orientation, marital status,
religion, honorably discharged veteran or military status,
or the use of a trained dog guide or service animal by a
person with a disability.
DSHS and HCA:
•
Provide free aids and services to people
with disabilities so they can communicate
effectively with us, such as:
• Qualified sign language interpreters
• Written information in other
formats (large print, audio,
accessible electronic formats, other
formats)
•
Provide free language services to people whose
primary language is not English, such as:
• Qualified interpreters
• Information written in other languages
If you need these services, contact 1-855-567-0252.
If you believe that DSHS or HCA has failed to provide
these services or discriminated in another way, you can
file a grievance with:
• DSHS
ATTN: Constituent Services
PO Box 45131
Olympia, WA 98504-5131
1-800-737-0617
Fax: 1-888-338-7410
askdshs@dshs.wa.gov
• HCA Division of Legal Services
ATTN: Compliance Officer
PO Box 42704
Olympia, WA 98501-2704
1-855-682-0787
Fax: 1-360-507-9234
You can file a grievance in person or by phone, mail,
fax, or email. If you need help filing a grievance, the
DSHS Constituent Services or HCA Division of Legal
Services is available to help you.
ii
You can also file a civil rights complaint with the U.S.
Department of Health and Human Services, Office for
Civil Rights electronically at
https://ocrportal.hhs.gov/ocr/portal/lobby.jsf, or by
mail or phone at:
U.S. Department of Health and Human Services
200 Independence Avenue SW
Room 509F, HHH Building
Washington, D.C. 20201
1-800-368-1019, 800-537-7697 (TDD).
Complaint forms are available at
www.hhs.gov/ocr/office/file/index.html.
Your responsibilities (you must):
If requested by the agency, provide any information
or proof needed to decide if you are eligible.
SSN and Immigration Status Disclosure. You have to
give us your Social Security Number (SSN) or
immigration document number. We need this to
decide if you are eligible. We use your SSN to confirm
your identity, citizenship, immigration status, date of
birth, and whether you have other health care
coverage. We do not share this information with
Homeland Security.
Report changes as required in our rules within 30
days of the change. Read your approval letter to see
what changes you must report.
Complete renewals when we ask you.
Cooperate with Quality Assurance staff if we
ask you to.
Things you should know:
There are state and federal laws that govern how
we process your application. They also govern your
rights and your responsibilities as an applicant and if
you get TSOA services, too. By applying, you agree
to follow these laws. If you get TSOA, you agree to
follow the laws that apply.
A federal law requires us to help you register to
vote if you want to. You can decide to register or
not. That decision will not affect our decision about
services or benefits. You can also register to vote at
www.vote.wa.gov or get a voter registration form
by calling 1-800-448-4881.
Health Insurance Portability and Accountability Act
(HIPAA) restrictions prevent HCA and DSHS from
discussing the health information of you or any
member of your household with anyone, including an
authorized representative, unless that individual has
power of attorney or you have signed a consent form
authorizing the disclosure of this information. This
includes disclosure of mental health information, HIV,
AIDS, STD test results, or treatment and chemical
dependency services.
The Affordable Care Act prevents DSHS from giving
the personally identifiable information (PII) of you
or any member of your household to anyone who is
not authorized to receive it.
The information that you give DSHS is subject to
verification by federal and state officials for
purposes of determining your eligibility for the
TSOA program. Verification can include follow-up
contacts from DSHS staff.
iii
iv
Tailored Supports for Older Adults (TSOA) Application
I. Applicant Name and Contact Information
1. First name
Middle initial
Last name
2. Client ID (if you know it)
3. Address where you live
C
i
ty
State
ZIP code
4. Mailing address (if different)
City
State
ZIP code
5. Primary phone number
Home Cell Message
( )
6. Secondary phone number
Home Cell Message
( )
II. Caregiver Name and Contact Information
Check here if you do not have a caregiver
7. Name of your caregiver
8. Phone number
Home Cell Message
( )
9. Address of caregiver
C
ity
State
ZIP code
10. Relationship to you
III. Authorized Representative Information
An authorized representative is an adult you authorize to act on your behalf about your application. Your authorized
representative can sign and submit your application for you and can receive letters about it from us. An organization
can also be your authorized representative if the organization is your guardian.
1.
Do you have an authorized representative? Yes No
2.
Do you want your authorized representative to receive letters from us about your application? Yes No
3.
Is your authorized representative also your legal guardian? Yes No
If yes, who:
4.
Is your authorized representative also your power of attorney? Yes No
If yes, who:
5.
Is your authorized representative also your caregiver? Yes No
6.
Authorized representative name/organization
7. Phone number
( )
8. Mailing address of authorized representative
IV. Marital Status
Not married
Married living with spouse
Married living apart from spouse
In a registered domestic partnership
HCA 18-008 (7/20)
1.
V. Information About Your Household
(List only yourself and your spouse, if married)
Optional for your spouse if not
applying for TSOA
Name
(First, middle, last)
Sex:
M
or F
How is
this
person
related to
you?
Date of
birth
Check if
you
want
services
for this
person
Social Security
number
Check
if U.S.
Citizen
Race
(see below)
Tribe name
(for American
Indians, Alaska
Natives)
Myself
Spouse
VI. General Information
1. My ethnic background is Hispanic or Latino: Yes No Note: Race and Ethnic background information is
voluntary.
(Race examples: White, Black or African American, Asian, Native Hawaiian, Pacific Islander, American Indian, Alaska
Native, or any combination of races)
2. My spouse or I is a sponsored alien? Yes No If yes, who?
3. I need an interpreter. I speak: ___________________ or sign;
translate my letters into: _______________________________
VII. Earned Income
(Attach Proof – For example your paystub or a statement from your employer)
Note: American Indians/Alaska Natives do not have to report certain income, such as distributions from Alaska Native Corporations and
Settlement Trusts, property held in trust, and ownership of natural resources
and improvements; payments from fishing, natural resource
extraction and harvests; payments from ownership of items that have unique religious, spiritual, traditional, or cultural significance; and
Bureau of Indian Affairs student financial assistance.
1. I have income from work? Yes No
Employer’s name
Employer’s phone
Date I started this job
Is this job self-employment? Yes No
Gross amount received (dollar amount before deductions)
$ ______ every: Hour Week Two weeks Twice a month Monthly
Hours per week: ______ Pay dates (e.g., 1
st
and 15
th
, or every Friday): ______
2. My spouse has income from work? Yes No
Spouse’s employer’s name
Spouse’s employer’s phone
Date spouse started this job
Is this job self-employment? Yes No
Gross amount received (dollar amount before deductions)
$ ______ every:
Hour
Week
Two weeks
Twice a month Monthly
Hours per week: ______ Pay dates (e.g., 1
st
and 15
th
, or every Friday): ______
2.
VIII. All Other Income (You or your spouse)
(Attach Proof – For example, award letters, statements, annuity documents)
Examples are:
● Social Security
● Unemployment
benefits
● IRA/401(k))
● Pension
● Interests/dividends
● Labor and Industries
(L&I)
● Railroad benefits
● Sales contracts/
promissory notes
● Spousal maintenance
● Tribal income
●
Veteran
Administration (VA)
or Military Benefits
●
Gifts (cash support/
gift cards
● Rental income
● Trusts
● Annuity
Unearned Income Type Who Gets the Income
Gross Monthly
Amount
Who Gets the Income
Gross Monthly
Amount
$ $
$ $
IX. Resources
(Attach Proof – For example, copies of bank statements, legal documents or insurance policies)
A resource is anything you own or are buying that can be sold, traded, or converted into cash or money. This includes
things held by others. A resource does not include personal property such as furniture, clothing, personal effects, including
jewelry.
Examples of resources are:
● Cash
● Checking
accounts/CDs
● Stocks/bonds
● Mutual funds
● Your home
● IRA/401K/
retirement funds
● Land/other
property
● Life estate
● Life insurance
policies
● College funds
● Timeshares
● Trusts/annuities
● Funeral
arrangements
● Farm equipment/
livestock
● Business
equipment
● Sales contracts
Resource Type
Who Owns
Location
Value
Resource Type
Who Owns
Location
Value
$
$
$
$
$
$
VEHICLES: List any vehicles owned by you and your spouse. This includes: cars, trucks, vans, boats, RVs, trailers, or other
motor vehicles.
Year (e.g., 2010)
Make (Toyota)
Model (Camry)
Check if Leased
Amount Owed
$
$
X. Read Carefully Before Signing
Administrative Hearing Rights: If you disagree with a decision we made, you can file an appeal to have a hearing. You may
also ask a supervisor and administrator for help. You can still have a hearing even if you ask for this help.
3.
XI. Voter Registration
The Department offers voter registration services, including automatic voter registration.
Applying to register or declining to register to vote will not affect the services or amount of benefits that you may receive
from this agency. If you would like help filling out the voter registration form, we will help you. The decision whether to seek or
accept help is yours. You may fill out the voter registration form in private. If you believe that someone has interfered with your
right to register or to decline to register to vote, your right to privacy in deciding whether to register or in applying to register
to vote, or your right to choose your own political party or other political preference, you may file a complaint with:
Washington State Elections Office PO Box 40229, Olympia, WA 98504-0229 (1-800-448-4881)
Do you want to register to vote or update your voter registration? Yes No
If you do not check either box, we will consider you to have decided not to register to vote at this time, unless you are eligible
for, and do not decline, automatic voter registration.
Unless you checked “No” above, you may be eligible for automatic voter registration. You are eligible for automatic voter
registration if you will be at least 18 years
old by the next election, you are a citizen of the United States of America, and
DSHS has your name, residential and mailing address, date of birth, verification of citizenship information, and your signature
attesting to the truth of the information prov
ided on this application.
Do you want to be automatically registered to vote?
Yes No
If you checked the box marked “Yes,”
or do not check either box and you meet automatic voter registration eligibility
requirements, DSHS will send your information to the Office of the Secretary of State and you will be automatically
registered to vote.
XI. Declaration and Signature
I have read and understood the information in this application. I declare, under penalty of perjury under the laws of the State of
Washington, that the information I have given in this application, including the information concerning my citizenship and
immigration status, is true, correct, and complete to the best of my knowledge.
Signature of Applicant or Authorized Representative
Date
Printed Name of Applicant or Authorized Representative
4.
