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LTSS Required Supplemental Forms Name of Form Used in: Details Applicant sends to: Consent Form, DHS- 25M-CL Provider

Clinical/functiona l eligibility Supplemental form for health provider which authorizes release of health care information. Two copies included in the application packet to be sent to health care provider and/or community agency Provider Health Care Provider Authorization to Obtain or Release Confidential Information, DHS-25 (New consolidated form that incorporates DHS- 91) General/financial eligibility Release for non- medical confidential information Agency with DHS-2 3. Limits on Application Information – As the DHS-2 is an integrated application that is used across health and human services programs, applicants must answer questions that are sorted by program. Applicants are responsible for answering only those questions pertaining to eligibility for the programs for which they are applying: a. On the paper application, the relevant questions are marked with the acronym associated with the specific programs for which the applicant is applying. “KB” means Katie Beckett, “LTSS” means long-term services and supports b. Applicants using the electronic version of the DHS-2 may identify the programs for which they are applying upfront. The IES then automatically sorts the questions they must answer by their program(s) of choice. D. Application Assistance. DHS and EOHHS eligibility specialists provide application assistance in completing all necessary forms, obtaining and submitting required documentation, and responding to inquiries or requests for information. Assistance is also available through:

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Official source

LTSS Required Supplemental Forms Name of Form Used in: Details Applicant sends to: Consent Form, DHS- 25M-CL Provider

Clinical/functiona l eligibility Supplemental form for health provider which authorizes release of health care information. Two copies included in the application packet to be sent to health care provider and/or community agency Provider Health Care Provider Authorization to Obtain or Release Confidential Information, DHS-25 (New consolidated form that incorporates DHS- 91) General/financial eligibility Release for non- medical confidential information Agency with DHS-2 3. Limits on Application Information – As the DHS-2 is an integrated application that is used across health and human services programs, applicants must answer questions that are sorted by program. Applicants are responsible for answering only those questions pertaining to eligibility for the programs for which they are applying: a. On the paper application, the relevant questions are marked with the acronym associated with the specific programs for which the applicant is applying. “KB” means Katie Beckett, “LTSS” means long-term services and supports b. Applicants using the electronic version of the DHS-2 may identify the programs for which they are applying upfront. The IES then automatically sorts the questions they must answer by their program(s) of choice. D. Application Assistance. DHS and EOHHS eligibility specialists provide application assistance in completing all necessary forms, obtaining and submitting required documentation, and responding to inquiries or requests for information. Assistance is also available through: