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Services, whether state or medicaid funded, you must complete this form. Low Intensity Support Services (LISS) do not require an application. If you need help with this application, call Toll Free 1-877-4MD-DHMH * TTY for Disabled - Maryland Relay service 1-800-735-2258 PART I: APPLICANT'S INFORMATION LAST Name FIRST Name Date of Birth (MM/DD/YYYY): MIDDLE Name Social Security Number: Permanent Mailing Address: Apt# Street Address City State Are you a resident of Maryland? Yes Teleph.

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