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This application is for Long Term Facility Care or Home and Community Based Services Waiver Programs or the Program of All Inclusive Care for the Elderly.

 If you need help filling out this application or have questions about Long Term Care, please call us toll-free at 1-888-544-7996 Monday through Friday between 8 a.m. and 4:30 p.m.

If you are deaf or have hearing problems, call the TTY line at 1-800-220-5404

Files	Size	Format
Medicaid Application for Long Term Care	718 kb	Adobe PDF	download viewer
Instructions for Medicaid Long-Term Care Application	47 kb	Adobe PDF	download viewer
Long Term Care Pre-Application Checklist	204 kb	Adobe PDF	download viewer