[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-200750-105":3,"detail-sidebar-cat-1-en-105":81,"doc-detail-200750-en":127},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","medical-assistance-medicaid-financial-eligibility-application-for-long-term-care-supports-and-services-application-instructions","Medical Assistance (Medicaid) Financial Eligibility Application for Long Term Care, Supports and Services - Application Instructions","","Medical Assistance (Medicaid) financial eligibility application for long term care, supports and services, covering which care options are being requested, language and interpreter preferences, and the applicant’s identification and personal details. The form outlines how to complete unshaded sections, correct preprinted information, and submit required verification documents. It also explains representative eligibility, the potential impact of transferring assets or creating trusts within the prior 60 months, and expected timelines for county assistance office notification.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/medical-assistance-medicaid-financial-eligibility-application-for-long-term-care-supports-and-services-application-instructions/200750/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/medical-assistance-medicaid-financial-eligibility-application-for-long-term-care-supports-and-services-application-instructions/200750.png","ImageObject",442,249,{"name":42,"@type":43},"Lucas Martin","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-30","2026-09-04",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",9,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"What information must be provided in the unshaded sections of the application?","Question",{"text":63,"@type":64},"The form instructs the applicant to print the requested information in the unshaded sections and to review all questions without a preprinted response, providing answers unless instructions allow not answering.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"Can someone else complete the application on my behalf?",{"text":68,"@type":64},"Yes. A representative may complete the application, including a spouse, friend, relative, power of attorney holder, or medical provider, as long as the person can provide information about the applicant’s income and resources.",{"name":70,"@type":61,"acceptedAnswer":71},"How does transferring assets or setting up a trust affect eligibility?",{"text":72,"@type":64},"If assets were given away or transferred to a trust within the last 60 months before applying for long term care services, the applicant may be ineligible. Verification may be needed for assets owned during that period even if no longer owned.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},200750,1788511968,{"code":4,"msg":82,"data":83},"success",[84,89,94,99,104,109,113,118,123],{"id":85,"doc_module":22,"doc_module_name":25,"category_name":86,"show_sort_weight":87,"slug":88},11,"Presentations",90,"presentations",{"id":90,"doc_module":22,"doc_module_name":25,"category_name":91,"show_sort_weight":92,"slug":93},12,"Resumes",80,"resumes",{"id":95,"doc_module":22,"doc_module_name":25,"category_name":96,"show_sort_weight":97,"slug":98},14,"Invoices",70,"invoices",{"id":100,"doc_module":22,"doc_module_name":25,"category_name":101,"show_sort_weight":102,"slug":103},15,"Posters",60,"posters",{"id":105,"doc_module":22,"doc_module_name":25,"category_name":106,"show_sort_weight":107,"slug":108},16,"Social Media",50,"social-media",{"id":110,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":111,"slug":112},17,40,"forms",{"id":114,"doc_module":22,"doc_module_name":25,"category_name":115,"show_sort_weight":116,"slug":117},18,"Letters",30,"letters",{"id":119,"doc_module":22,"doc_module_name":25,"category_name":120,"show_sort_weight":121,"slug":122},21,"Paper Templates",5,"papers-templates",{"id":124,"doc_module":22,"doc_module_name":25,"category_name":125,"show_sort_weight":4,"slug":126},158,"General","general-158",{"code":4,"msg":82,"data":128},{"doc_id":79,"user_id":129,"nickname":42,"user_avatar":130,"doc_module":22,"category_id":110,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":90,"language":136,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":12,"update_tm":80,"read_time":33},8796095360427,"https://ap-avatar.wpscdn.com/davatar_994ba38a5ba835b3df7d355c54d3ed8d","Medical Assistance (Medicaid) Financial Eligibility Application for Long Term Care, Supports and Services  \nCheck any that you are applying for:  \n Care in a facility  \n Home and Community Waiver Services – Type/Name of Waiver/Service:    Other:    \n• Please read the entire form.  \n• Print the requested information in the unshaded sections.  \n• If you need help, another person can help you or you can get help from your county assistance office.  \n• Please review any information printed on this form. If any already printed information is incorrect or has changed, strikeout the printed information and provide updated information. Please review all questions that do not have a printed response and provide a response unless the instructions tell you that you can choose not to answer.  \nYou or any representative you choose may complete this application. Your representative can be your spouse, a friend, a relative, a person who has your power of attorney, or your medical provider. It should be someone who knows and can provide information about your income and resources. If you are married, information in some sections must be completed for both you and your spouse.  \nAfter the form is completed, bring it, have someone else bring it, or mail it to the county assistance office unless you are instructed otherwise. The county assistance office will tell you if an interview  \nis needed. You will need proof of identity and verification for other information on the form unless we already have the information in our records. If you need help to obtain any information ask the county assistance office for help. You should attach verification to this form.  \nPersons who have given away assets (income or resources) within the past 60 months, or set up or transferred assets to a trust within the last 60 months prior to applying for Medical Assistance for long term care, supports and services may be ineligible for benefits. Because of this requirement, you may need to provide verification of assets owned during the past 60 months eventhough you may no longer own them. We will use your Social Security number to get information about your assets for the 60 months prior to your application.  \nIf the information is complete and you have provided the necessary verification (with this form, if possible) the county assistance office will notify you within 30 days of receiving your application if you are eligible, ineligible, or if additional information is needed.  \nThis is an application for Medical Assistance benefits. If you need help translating it, please contact your county assistance office, CAO. Translation services will be provided free of charge.  \nEsta es una solicitud de beneficios de Asistencia Médica. Si necesita ayuda con la traducción comuníquese con la Oficina de Asistencia del Condado (CAO) que le corresponde. Los servicios de traducción son gratuitos.  \nهذا طلب للحصول على منافع المساعدة الطبیة. إذا كنت بحاجة إلىمساعدة في ترجمته، يرجى الاتصال بمكتب معونة مقاطعتك CAO.ستقدم خدمات الترجمة مجانًا.  \nPlease call Inspiritec at 1-866-550-4355 for assistance completing your Medical Assistance application over the phone. You can [also apply online at:](also apply online at: www.dhs.pa.gov/compass)[ ](also apply online at: www.dhs.pa.gov/compass)[www.dhs.pa.gov/compass](also apply online at: www.dhs.pa.gov/compass).  \nPage 1 PA 600 L (AS) 3/26  \n\n| DO NOT COMPLETE – PROVIDER USE ONLY |  |  |  |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| PROVIDER NAME |  |  |  |  |  | NUMBER |  |  |  |\n| ADDRESS |  |  |  |  |  | CONTACT NAME/TELEPHONE NUMBER |  |  |  |\n| DATE OF ADMISSION |  |  | DATE OF LEVEL OF CARE DETERMINATION |  |  |  | REQUESTED EFFECTIVE DATE |  |  |\n| DO NOT COMPLETE-COUNTY ASSISTANCE OFFICE USE ONLY |  |  |  |  |  |  |  |  |  |\n| CO. | DIST | RECORD NUMBER |  | FILE CLEARED BY | APPL. REG. NO. |  |  | WORKER I. D. | CASELOAD |\n|  AUTHORIZED REASON |  |  |  |  |  |  |  | CATEGORY |  |\n| \u003Cbr> NOT AU","cbCaisTluboN5HMm","https://ap.wps.com/l/cbCaisTluboN5HMm","pdf",432249,"English","# Getting Started\n## Language and Interpreter Preferences\n# Applicant Information\n## Personal Details\n## Marital Status and Dates\n## Race (Optional)\n## Current Address and Contact\n# Prior Benefits and Program History\n## Applications in Other Counties/States","[{\"question\":\"What information must be provided in the unshaded sections of the application?\",\"answer\":\"The form instructs the applicant to print the requested information in the unshaded sections and to review all questions without a preprinted response, providing answers unless instructions allow not answering.\"},{\"question\":\"Can someone else complete the application on my behalf?\",\"answer\":\"Yes. A representative may complete the application, including a spouse, friend, relative, power of attorney holder, or medical provider, as long as the person can provide information about the applicant’s income and resources.\"},{\"question\":\"How does transferring assets or setting up a trust affect eligibility?\",\"answer\":\"If assets were given away or transferred to a trust within the last 60 months before applying for long term care services, the applicant may be ineligible. Verification may be needed for assets owned during that period even if no longer owned.\"}]","Medical Assistance (Medicaid) Financial Eligibility Application for Long Term Care, Supports and Services - Application Instructions | PDF"]