Medical Care Received Form (DHS-6059A)
The Medical Care Received form (DHS-6059A) (PDF) must be sent to clients requesting LTC services when an LTC income calculation will be used to determine the client’s eligibility if the client has not completed a DHS-3543, Request for Payment of Long-Term Care Services. The client records on the form the medical care received and expenses incurred in the three months prior to the month in which the LTC request was received.
Send the DHS- 6059A to every person who requests MA-LTC and will use an LTC income calculation who has not submitted their request on a DHS-3543. Send the form if uncertain at the time of the MA-LTC request based on the information reported. Before sending, enter:
- The header information on the first page.
- The ‘Agency Use’ information on the second page.
- The date on the second page. The date defines the timeframe of allowable expenses. Enter in this field the first of the month that is three months prior to the receipt month of the MA-LTC request.
Have the client or the authorized representative complete the form, if possible, at the time of an interview. If they are unable to complete the form at that time, explain the importance of its timely return.
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The MA-LTC Medical Expense Deduction - Forms