; and (B) provide, in the case of such a Survivor, for medical assistance under the State Medicaid plan to such Survivor during such period based on the family income level eligibility requirements established under the State Medicaid plan or, if higher, under the State Medicaid plan of the State in which such Survivor resided as of September 17, 2017. (2) Streamlined procedures The streamlined procedures described in this paragraph, with respect to a State and an applicant for medical assistance under the State Medicaid plan, are the following: (A) Common application form Use of a common 1-page application form developed by the Secretary of Health and Human Services, in consultation with the National Association of State Medicaid Directors. Such form shall— (i) require an applicant to provide an expected address for the duration of the DRM coverage period and to agree to update that information if it changes during such period; (ii) include notice regarding the penalties for making a fraudulent application; (iii) require the applicant to assign to the State any rights of the applicant (or any other person who is a DRM-eligible Maria Survivor and on whose behalf the applicant has the legal authority to execute an assignment of such rights) under any group health plan or other third-party coverage for health care