Section 210-RICR-50-00-4.10 - Applicant and Agency ResponsibilitiesA. Applicant responsibilities include: 1. Full responses -- Responding to all questions related to LTSS eligibility on the application and any required supplemental forms;2. Providing any documentation requested to verify the information on the form at the time the application is submitted and at any point in which change reporting is due;3. Promptly sending to health care providers the signed clinical evaluation forms and associated releases and ensuring these forms are returned in a timely manner.4. Clinical status --Reporting any changes in health status, such as trauma or marked decline in functional ability, financial circumstances, such as sale of a home, asset loss or windfall, and/or household composition, such as death or divorce of a spouse, that may affect the determination of level of need after the initial application is submitted during the time the application is pending action by the State.5. Signature and truthfulness -- Signing the form to provide consent for the determination of eligibility and the verification of information through electronic sources and to attest to the truthfulness of application responses. In the event of a death, the form may be signed by an authorized representative or next of kin.6. Duty to Report -- Applicants must report changes in any information included on the application and supplemental forms within ten (10) days from the date the change takes effect while the application is open. Self-reports are permitted through the eligibility system consumer self-service portal as well as in person, via fax, or mail. Failure to report in a timely manner may result in the denial of an application based on non-cooperation.7. Documentation/proof -- Applicants must provide any documentation or proof that otherwise cannot be obtained related to any eligibility factors subject to change upon written request. The information must be provided within the time frame specified in the notice stating the basis for making the agency's request. Failure to respond in a timely manner and/or to provide the information requested without good cause is considered to be non-cooperation and is grounds for denial.8. Financial resources -- Applicants must, as a condition of eligibility, take any necessary steps to obtain annuities, pensions, retirement and disability benefits along with any other forms of assistance available for support and maintenance that may be identified by the agency, in writing, in accordance with §40-00-2.5 of this Title. Good cause exceptions are considered when requested in writing.B. State Agency responsibilities include: 1. Assistance -- Applicants who are incapacitated or are otherwise unable to fulfill these responsibilities on their own or with the assistance of an authorized representative may request additional assistance from an LTSS eligibility specialist. The EOHHS reserves the discretion to authorize such assistance the Secretary or his or her designee deems appropriate.2. Voluntary Withdrawal - An applicant may request that an application for Medicaid benefits be withdrawn at any time either through their secure on-line account or by submitting the request in writing via the U.S. Mail or fax to the EOHHS or DHS agency representative. The Medicaid agency sends a notice to the applicant verifying the time and date of the voluntary withdrawal and indicating that the applicant may re-apply at any time.3. Privacy of Application Information - Application information must only be used to determine eligibility and the types of benefits a person is qualified to receive. Accordingly, the EOHHS, the agencies under its umbrella, and all other entities serving as its agents in the Medicaid eligibility process maintain the privacy and confidentiality of all application information and in the manner required by applicable federal and State laws and regulations.4. Application Timeliness -An applicant may appeal and request a hearing on the basis of the timeliness if the State fails to provide notification of outstanding documentation and make a determination of eligibility on an application within the ninety (90) day review period.5. State Payments - In accordance with R.I. Gen. Laws § 40-8-6.1, an LTSS provider may request State-only payment for LTSS if a determination of eligibility on a completed application, as defined herein, has been pending for more than ninety (90) days without action taken by the State.210 R.I. Code R. 210-RICR-50-00-4.10