Provider Resources:
- LTC Medicaid Application - 202LTC APPL - Applicants must complete this application to start the financial and clinical evaluation.
- Medical Retroactive Medicaid Request form - 202A (2/16/2023)
- Authorized Representative - 139REP (2/16/2023)
- Long Term Care Recovery from Estates - 204REC (2/16/2023)
- Burial Intention Statement form - 216BF (2/16/2023)
- Information Release Authorization - 201B (2/16/2023)
- Authorization for Verification of Resources - 202NAS (2/16/2023)
- Alternate Reporter - 139AR (2/16/2023)
- LTC Medicaid Renewal form - 202LTC REV (4/25/2023)
AHS Document Uploader - Need to send us documents? You can use the document uploader website to send them right from your computer, phone or tablet. See flyer for detailed instructions.