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) 
• Savings/Checking Account Request for Information  (DHS-91)
• Certification of Citizenship/Alienage  (DHS-SAV-1)
• Liens and Recovery Notice  (MA-89 LR) -signature is voluntary
• Home and Community Based Waiver-Notification of Recipient Choice  (CP-12)
• Race/Ethnicity Form  (RE-1) - completing this is voluntary
• HIPAA Notice of Privacy Practices  (HIPAA-1)
• Medical Assessment for DEA Home and Community Based Care  (HCC-1C)
• Medical Evaluation of Applicant for Level of Care  (GW-OMR-PM-1)
• Ownership of Real Estate (MA-400)

For help with the application, please call a DHS Long Term Care office, DEA Home and Community Care, one of the DEA Case Management Agencies or the Point.

DHS Long Term Care Offices































DEA Case Management Agencies































DEA Home and Community Care (401) 462-0570































The Point  (401) 462-4444