All LTC applicants are required to complete and sign Additional Financial Information for Long Term Care Applicants (HFS 3654). This form is used to obtain additional financial information and assess financial management.
By completing and signing HFS 3654, consent is given to any investigation made by the Department to verify information on the form. Completing and signing HFS 3654 is a condition of eligibility. If the applicant or representative refuses to complete and sign HFS 3654, the person is ineligible for LTC medical assistance but may be determined eligible for AABD community medical assistance.