If you need help in completing this application or need interpreter services, please contact ACCESS Florida at 1-BGG-762-17. Spousal refusal acts as a loophole, allowing the non-applicant spouse to refuse to pay for care and allowing the applicant spouse to claim benefits anyway.Under the Medicaid spousal impoverishment provisions, a certain amount of the couple's combined resources is protected for the spouse living in the community. The quickest way to apply for Government Assistance is online through the MyACCESS portal. The current Medicaid rules call for a "division of assets. Since the nonapplicant spouse has refused to "support" their spouse, this form assigns the right to support to the state. This form may be used if a dissolution of marriage has not been filed, and you are requesting alimony. The applicant must also fill out a spousal refusal form when submitting the Medicaid application. {Name}. , may not help me fill in the form and may not complete the form for me. After completing this form, you should sign the form before a notary public or deputy clerk.