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 completing the application, see the phone numbers and links at the bottom of this page.
- 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)
- Special Needs Trust Review Request-Cover Letter and Form
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:
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Executive Office of Health and Human Services
Cranston, RI 02920
Connect
State of Rhode Island
