Request for Payment of Long Term Care Services (DHS-3543)
The Request for Payment of Long-Term Care Services (DHS-3543) (PDF) may be used to request payment of long-term care services as well as document expenses that may be used in a LTC income calculation. The client records on the form under question 6 the medical care received and expenses incurred in the three months before the month in which they want LTC services to begin.
Client should provide the completed form along with verifications of the expenses listed on Question 6, within the processing period.
Verifications of medical expenses may include:
- Copies of bills.
- Receipts.
- Proof of payment made by Medicare, other insurance or other payments made on the client's behalf.
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MA-LTC Medical Expense Deduction - Forms