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DDS Eligibility Forms

Use these forms to apply for DDS services

We have recently changed our application forms and process. The new forms will provide DDS with the information needed to determine eligibility. Eligibility must be determined to get DDS services.

Please see the first list below if you're looking for an application for an individual who is four years old or younger.

Please see the second list for individuals who are between five and 22 or individuals who are older than 22.

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Eligibility Application – Birth Through Age Four

DDS Eligibility Application Birth to 4 years (English), Open PDF file, 415.67 KB (English, PDF 415.67 KB)
DDS Eligibility Application Birth to 4 years (Arabic) , Open PDF file, 483.62 KB (Arabic, PDF 483.62 KB)
DDS Eligibility Application Birth to 4 years (Chinese), Open PDF file, 557.28 KB (Chinese, Traditional, PDF 557.28 KB)
DDS Eligibility Application Birth to 4 years (Portuguese), Open PDF file, 391.92 KB (Portuguese, Portugal, PDF 391.92 KB)
DDS Eligibility Application Birth to 4 years (Spanish), Open PDF file, 334.72 KB (Spanish, PDF 334.72 KB)

Eligibility Application – Age 5 to 22 and 22+

DDS Eligibility Application for Ages 5-22 and Ages 22 and Above (English) , Open PDF file, 426.7 KB (English, PDF 426.7 KB)
DDS Eligibility Application for Ages 5-22 and Ages 22 and Above (Arabic), Open PDF file, 483.62 KB (Arabic, PDF 483.62 KB)
DDS Eligibility Application for Ages 5-22 and Ages 22 and Above (Bengali), Open PDF file, 988.33 KB (English, PDF 988.33 KB)
DDS Eligibility Application for Ages 5-22 and Ages 22 and Above (Chinese), Open PDF file, 516.56 KB (Chinese, Traditional, PDF 516.56 KB)
DDS Eligibility Application for Ages 5-22 and Ages 22 and Above (Haitian Creole), Open PDF file, 688.14 KB (Haitian Creole, PDF 688.14 KB)
DDS Eligibility Application for Ages 5-22 and Ages 22 and Above (Portuguese), Open PDF file, 353 KB (Portuguese, Portugal, PDF 353 KB)
DDS Eligibility Application for Ages 5-22 and Ages 22 and Above (Russian), Open PDF file, 645.6 KB (Russian, PDF 645.6 KB)
DDS Eligibility Application for Ages 5-22 and Ages 22 and Above (Somali), Open PDF file, 552.2 KB (Somali, PDF 552.2 KB)
DDS Eligibility Application for Ages 5-22 and Ages 22 and Above (Spanish), Open PDF file, 334.72 KB (Spanish, PDF 334.72 KB)
DDS Eligibility Application for Ages 5-22 and Ages 22 and Above (Vietnamese), Open PDF file, 947.04 KB (Vietnamese, PDF 947.04 KB)

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