Form Appendix D, Aged, Blind or Disabled / Long-Term Care Supplement⊛ Official Government Form
Virginia Department of Medical Assistance Services (DMAS) — Cover Virginia
Official Government Form
The form shown here is the official original from the agency.
TNT Language Guide
Translation and explanations are aids to understanding and do not replace the official form.
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Select a numbered box on the form to see what it is asking for.