PM 01-02-01-a

All LTC applicants are required to complete New textand sign Additional Financial Information for Long Term Care Applicants (HFS 3654). This form is used to obtain additional financial information and assess financial management.

Deleted textBy Revised textcompleting and signing HFS 3654, consent is given to any investigation made by the Department to verify information on the form. Revised textCompleting and signing HFS 3654 is a condition of eligibility. If the applicant or representative refuses to Revised textcomplete and sign HFS 3654, Revised textthe person is ineligible for LTC medical assistance but may be determined eligible for AABD community medical assistance. Deleted text