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: 

• DHS Long Term Care Offices 
• DEA Home and Community Care
• DEA Case Management Agencies 
• Or call the POINT at (401) 462-4444.

DEA Case Management Agencies































DEA Home and Community Care (401) 462-0570































The Point  (401) 462-4444