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Patients with disabilities or chronic care needs may benefit from higher levels of care and support to optimize their health and retain independence in activities of daily living through the Department of Human Service (DHS). These supports may be at the level of the home or community-based. Specific services that may be accessible to patients include meals delivery programs such as meals on wheels, placement with a certified nursing assistant to help with daily activities (up to 50 hours per week of cooking and cleaning by a CNA), or placement in a nursing home (for an unlimited period of time).

This medical provider assessment should be filled out by a provider and sent to the DHS when advocating for higher levels of care for patients. Within the form, the provider will be asked to evaluate and document a patient’s medical diagnoses, levels of pain and discomfort, capacity to perform activities of daily living, and any impairments to cognitive status. 

In addition to the medical provider assessment, providers should also assist patients in filling out the DHS LTSS application if possible, as the form is rather long and may be challenging for patients to complete.

Note: This paperwork can be time-consuming, so you might consider scheduling an appointment specifically to help a patient apply for this resource.


  1. LTSS Medical Provider Assessment Form
  2. DHS LTSS Application

Next steps

This form should be completed and submitted to the Department of Human Service (DHS).