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LTSS. There are two types of forms required for Medicaid LTSS eligibility, however applying: 1. General Application Form – The DHS’ “Application of Assistance”, known as the “DHS-2”, is the principal application form a person must complete when applying for Medicaid LTSS. The paper version of the DHS-2 is available on-line at: at one of the DHS offices listed here. Community agencies and LTSS providers may also be able to provide copies of the DHS-2. The DHS-2 is used for LTSS and as the basis for determining eligibility for: Supplemental Nutrition Assistance Program (SNAP), Child Care Assistance Program (CCAP), Community Medicaid for elders and adults with disabilities (EAD) who are seeking long-term care, the Sherlock Plan for persons with disabilities who work (SP), the State- funded optional supplemental security program (SSP) and the RI Works Program. 2. Supplemental Forms – All applicants for LTSS must also complete additional forms that provide the information necessary to review the application and/or determine various eligibility factors. LTSS Required Supplemental Forms Name of Form Used in: Details Applicant sends to: DHS-2 Cover Sheet Application Identifies LTSS applicants and type of services requesting Agency with DHS-2 CP-12 Applicant Choice General Eligibility Applicant must attest that information about types of LTSS (institutional and HCBS) has been provided Agency with DHS-2 Clinical/functional evaluation by Health Care Provider, GW OMR PM 1 and supporting documentation Clinical/functiona l eligibility Form for health care provider to complete

Principal Health Care Provider (physician, NF, assisted living residence). Agency sends upon request and follows-up if no response by time of application review.