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The Request for Payment of Long-Term Care Services (DHS-3543) (PDF) may be used to request payment of long-term care services as well as document expenses that may be used in a LTC income calculation.

May 15, 2023 · LTC Screening Document, DHS-3427 (PDF) can be used for reference. For changes not related to an assessment, case managers should use DHS-3427 for updates as needed. Used with MnCHOICES? LTSS Notice of Action (Service Plan), DHS-2828B. Note: For information about when it is appropriate to use each form, refer to CBSM – Notice of action.

The DHS-3543 is a supplemental form used for current basic MA enrollees (or an enrollee of any MHCP, such as MSP only) who report they are moving to an LTCF or indicate they want to receive services through a waiver program.

DHS-3543 Request for Payment of Long-Term Care Services (PDF).

Jun 1, 2023 · MA enrollees who are requesting MA-LTC coverage of HCBS waiver services should submit one of the following forms: Claims for MA-LTC services cannot be paid until the enrollee is determined eligible for MA-LTC.

Nov 15, 2024 · Use the DHS eDocs searchable document library to search for and download forms, applications and other documents in other languages. Forms for the Early Intensive Developmental and Behavioral Intervention (EIDBI) benefit are located on EIDBI manual – Forms.

Use the Information for Long-Term Care (DHS 3543) to gather the additional information. • An applicant submits a form designed for a different population. For example, do not require a person with a disability who submits a DHS 3417 HCAPP to complete a DHS 3531 HCAPP. ... ... Assistance Payment for Long-Term Care Services?

Jan 23, 2024 · DHS 3543 Request for Payment of Long-Term Care Services This form is completed by enrollees who are requesting payment of long-term care services. DHS 8262 Minnesota Health Care Programs Renewal for Families, Children and Adults

Aug 1, 2009 · Long-Term Care/County Communication Form. The Long-Term Care/County Communication Form is used to aid communication between an LTCF and workers who determine eligibility for LTC services. The DHS-3050 includes a release of information.