Page 13

4.10 Applicant and Agency Responsibilities A. Applicant responsibilities include: 1. Full responses -- Responding to all questions related to LTSS eligibility on the application and any required supplemental forms; 2. Providing any documentation requested to verify the information on the form at the time the application is submitted and at any point in which change reporting is due; 3. Promptly sending to health care providers the signed clinical evaluation forms and associated releases and ensuring these forms are returned in a timely manner. 4. Clinical status --Reporting any changes in health status, such as trauma or marked decline in functional ability, financial circumstances, such as sale of a home, asset loss or windfall, and/or household composition, such as death or divorce of a spouse, that may affect the determination of level of need after the initial application is submitted during the time the application is pending action by the State. 5. Signature and truthfulness -- Signing the form to provide consent for the determination of eligibility and the verification of information through electronic sources and to attest to the truthfulness of application responses. In the event of a death, the form may be signed by an authorized representative or next of kin. 6. Duty to Report -- Applicants must report changes in any information included on the application and supplemental forms within ten (10) days from the date the change takes effect while the application is open. Self- reports are permitted through the eligibility system consumer self-service portal as well as in person, via fax, or mail. Failure to report in a timely manner may result in the denial of an application based on non- cooperation. 7. Documentation/proof -- Applicants must provide any documentation or proof that otherwise cannot be obtained related to any eligibility factors subject to change upon written request. The information must be provided within the time frame specified in the notice stating the basis for making the agency’s request. Failure to respond in a timely manner and/or to provide the information requested without good cause is considered to be non-cooperation and is grounds for denial. 8. Financial resources -- Applicants must, as a condition of eligibility, take any necessary steps to obtain annuities, pensions, retirement and disability benefits along with any other forms of assistance available for