Medicaid LTSS Application

The following application packet is used for determining eligibility for Medicaid Long Term Care [or Long Term Services and Supports (LTSS)].  For help with completing the application, see the phone numbers below.

• Application for Assistance Cover Sheet 
• Application for Assistance (DHS-2) 
• Application for Assistance (DHS-2)- Spanish
• Application for Assistance (DHS-2)- Portuguese
• Authorization for Disclosure/ Use of Health Information  (DHS-25M)
• Authorization to Obtain or Release Confidential Information (DHS-25) 
• Liens and Recovery Notice  (MA-89 LR) -signature is voluntary
• Home and Community Based Waiver-Notification of Recipient Choice  (CP-12) 
• LTSS Change Report/Program Change Form
• Medical Evaluation of Applicant for Level of Care  (GW-OMR-PM-1)
• Ownership of Real Estate (MA-400)

Nursing Home Forms

Click here for more information on the Nursing Home Transition Program (NHTP).

• Nursing Home Transition Program Referral Form
• SCW Evaluation of Care (AP 70.1)
• Identification for MI and DD (MA-PAS-1)

For help with the application, please call: 

• DHS Long Term Services and Supports Office 
• The POINT at (401) 462-4444