Overview

During the 2008 Legislative Session, the legislature passed Senate Bill 682 requiring the Department of Health and Mental Hygiene (DHMH) and the Department of Human Resources (DHR) to create uniform procedures, guidelines, and forms to be used by all employees in the determination of long-term care (LTC) Medical Assistance eligibility and to streamline regulations, policies, and procedures related to the application for LTC Medical Assistance Program services.

The LTC forms on this webpage are to be used consistently by all case managers in all LDSS. For more details please refer to the Action Transmittal #09-19 and Action Transmittal #12-02.

Forms

• 206c
• 726-MA-LTC
• CTAD
• DES-100
• OES-1000 (updated) 
• DES-2000
• DES-2001
• DES-2002
• DES-2003
• OES-2004 (revised August 2018)
• DES-2005
• DES-501
• DES-601A
• DES-601B
• DES-602
• DES-811
• DES-812
• DES-813
• DES-814
• DHMH-1159C
• DHMH-1159D
• DHMH-1169
• DHMH-259
• DHMH-4233
• DHMH-4235
• DHMH-4235A
• DHMH-4235B
• DHMH-4235C
• DHMH-4236
• DHMH-4240
• DHMH-4241
• DHMH-4242
• DHMH-4243
• DHMH-4244
• DHMH-4245
• DHMH-4246
• DHMH-4255
• DHMH-4342
• DHMH-4343
• DHMH-4354
• DHR/FIA 9709 (Revised 7-2017) 
  
• DHR/FIA 9709R (Revised 7-2017)​
  
• DHR/FIA 9709S (Fillable and Accessible)
• OES-001​​
• DHR/FIA 1052 LTC
• OES 014 (Fillable and Accessible)
• OES 014 (Non-Fillable)
• OES 014 (Microsoft Word)
• OES 015 (new; August 2018)