Long Term Care Program Medical Assistance Application
- Request For Action 1346
- Conversion Change Report Form
- Conversion Renewal Form
- Combined Application for Food, Medical and Cash Benefits
- Supplemental Form for Long Term Care Benefits
Long Term Care Program Medical Assistance Application FAQs
- 1346 FAQ
- Eligibility Quick Reference Guide
- Eligibility Determination and Enrollment Process for EPD Waiver: Response to G.W. Health Insurance Counseling Project (HICP) Fact Sheet (PDF)
- Retroactive Medicaid Application for Institutional Care (2018)
- Resource FAQ Sheet .pdf
- EPD FACT Sheet.pdf
- Financial Eligibility Institutional Care Fact Sheet.pdf
- Spend down FAQ Fact Sheet.pdf
Services My Way Forms
- PCA and PDCS Agreement (PDF)
Transfer Request Forms and Defective PA Forms
- Memo for Beneficiary Transfer Requests 09282016.pdf
- LTCA PA Request Notification 09282016.docx
- LTCA Defective PA Form (02032016) 07142016 Savable_final.pdf
- LTCA EPDW Transfer Form (02032016) 07142016 Savable_final.pdf
- LTCA State Plan Transfer Form (02032016) 07142016 Savable_Final.pdf
- Form 719A Prior Authorization Request
- Form - Request for Determination of Coverage and Pricing (3).pdf
Nursing Facility Forms
- PASRR Resources
- ePASRR Instructions Ver. 3 (PDF)
- DHCF ePASRR Level One Form
- Nursing Facility FAQ
- Retro Eligibility Attestation Form for Long Term Care Services and Supports (Fillable Form)
- Cover Page Out State Nursing Facility Placement (revised September 11, 2019) replace current cover page file (PDF)
- Proof of Contact (revised September 11, 2019) replace current proof of contact file (PDF)
- Beneficiary Agreement (revised September 11, 2019) (PDF)
- Request for Out of State Placement Form (revised September 11, 2019) (PDF)
POF: Prescription Order Form
DME MADS Referral Form