This information is used for Medicaid applications. It is not used for estate or life-planning.
I. General Information
Institutionalized Person______________________________________________________
SS # _________________ Birth date____________ Citizenship ______________________
Nursing Home______________________________________________________________
Date entered Hospital________________________________________________________
Date entered Nursing Home___________________________________________________
Veteran: Yes________ No ________
Spouse/Other(specify)________________________________________________________
Address___________________________________________________________________
City____________________________________State__________Zip__________________
Phone___________________________________Birth date__________________________
SS#________________________________ Citizenship ____________________________
Veteran: Yes_________ No _________
Please Bring a Copy of Any Estate Documents for the above Person/s (wills, powers of attorney, etc.)
Yes ___,No ___ Is there a Guardianship or Conservatorship for the institutionalized spouse? If your response is “Yes,” provide a copy of Guardianship and/or Conservatorship appointment papers.
Yes ___,No ___ Is there a disabled adult child? If yes please provide information in the “Disability” section below.
Yes ___,No ___ Has any child age 21 or over lived in the homestead for at least two years immediately before the client’s admission to the nursing home and provided care that would otherwise have required nursing home care as documented by a physician’s (M.D. or D.O.) statement.
Yes ___,No ___ Are there any co-owners of the home? If yes please provide information in the “Deeds”
section below.
Yes ___,No ___ Is the home in a trust? If yes please provide information in the “Deeds” section below
II. Income
State monthly amount and payee (who receives the income). Bring documentation for all answers.
$_____________ Social Security, Client ___________________
$_____________ Social Security, Spouse ___________________
$_____________ Supplemental Security Income? (SSI) Payee ___________________
$_____________ Pension Payee ___________________
$_____________ Other retirement ( IRA, annuity, 401K) Payee ___________________
$____________ Veteran’s Benefits Payee ___________________
$_____________ Disability Benefits Payee ___________________
$_____________ Annuities Payee ___________________
$_____________ Rent or Land Contract Payee ___________________
$_____________ Worker’s Compensation Payee ___________________
$_____________ Child Support Payee ___________________
$_____________ Unemployment Compensation Payee ___________________
$_____________ Income from proceeds of a lawsuit Payee ___________________
$_____________ Other Income (Please specify) Payee ___________________
III. Assets
Answer each item YES or NO. For each YES, list all assets owned by you and your spouse individually or jointly AND all assets owned jointly by you or your spouse and any other person. For each, provide the following:
1. Documentation which shows the current value of the asset.
2. “Snap Shot” (provide ONLY if a married Medicaid applicant) — documentation showing the asset value on the date the patient entered a long term care facility and then received continuous care 30 days or longer. The “snap shot” date is often the first date the patient entered a hospital and from
there transferred to a nursing home (the total number of continuous days under long term care totaling 30 or more). The “snap shot” date is used to determine the couple’s total “countable assets” (as defined by Medicaid rules) during the “initial assessment” process.
3. Provide documentation that shows the asset value three (3) months prior to the date of your appointment with our office.
* If you provide bank computer printout statements please have the representative sign and stamp the printout with the bank stamp.
Current “Snap Shot” Owner Name(s)
Value Date Value (specify “J” if jointly owned)
$_________ Owner _________________ Cash on Hand or in Safety Deposit Box
$_________ Owner _________________ Checking Account
$_________ Owner _________________ “
$_________ Owner _________________ Savings Account
$_________ Owner _________________ “
$_________ Owner _________________ “
$_________ Owner _________________ Certificate of Deposit
$_________ Owner _________________ “
$_________ Owner _________________ “
$_________ Owner _________________ Nursing Home Resident Trust Fund
$_________ Owner _________________ Savings Bonds
$_________ Owner _________________ Money Market Funds
$_________ Owner _________________ IRA, Keogh, 401K or deferred compensation acct
$_________ Owner _________________ Trust Funds
$_________ Owner _________________ Stocks or Mutual Funds
$_________ Owner _________________ Annuities
$_________ Owner _________________ T-Bills
$_________ Owner _________________ Mortgage, land contract or other notes payable to you
$_________ Owner _________________ Life Insurance policies
$_________ Owner _________________ Home
$_________ Owner _________________ Real estate other than home
$_________ Owner _________________ Car, van, truck, boat, camper, trailer, snowmobiles, other
$_________ Owner _________________ Funeral contracts
$_________ Owner _________________ Burial plots, casket, etc.
$_________ Owner _________________ Other (please specify)
$_________ Owner _________________ Other (please specify)
$_________ Owner _________________ Other (please specify)
IV. Trust Assets
Do you have a trust for the institutionalized person, spouse or a child? If so please write down the name and date of the trust and supply us a copy.
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________
V. Deeds
Do you have any real property, including the homestead? Any unrecorded deeds? Please
identify the property, the grantors (signors) and the grantees (recipients) and supply us a copy of the deeds.
__________________________________________________________________________________
__________________________________________________________________
VI. Gifts
Have you and/or your spouse given a monetary gift within the last 3 years? If YES, please
explain and bring all records of the gifts:
__________________________________________________________________________________
__________________________________________________________________________________
VII. One Time Payments
Yes ___,No ___ Have you and/or your spouse received a one-time cash payment in the last 36 months (3
years) such as an insurance settlement, lawsuit award, worker’s compensation, lottery winnings, etc.,
Do you have a pending lawsuit that may bring property or money to you? If YES, please explain and
bring all records of the payment: ________________________________________________________
__________________________________________________________________________________
VIII. Disabled Children
Do you have a child who is under the age 65 and receiving disability from Social Security? If so please identify the child and provide a copy of the awards of RSDI (Social Security) benefits
__________________________________________________________________________________
IX. Documents
We will need the following documents. Please bring them with you to your appointment.
Copy of you and your spouse’s social security card.
Copy of you and your spouse’s drivers license (even if expired).
Copy of you and your spouse’s Medicare card.
Copy of you and your spouse’s health insurance card.
Utility bills for the month of application.
Recent statement of Veteran’s benefits.
Recent statement of Homeowner’s insurance.
Recent mortgage statement.
Recent rent statement for your spouse.
Recent condominium fee statement.
Recent special assessment statement.
Recent tax bills for your and/or your spouse’s home and any other property you and/or
your spouse own.
Recent health insurance premium statement for you and your spouse.
Current social security benefit letter for you and your spouse.
Current pension letter for you and/or your spouse or pension check stub.
Copy of any Long Term Care Insurance policies.
Copy of birth certificate, passport, naturalization papers, citizenship papers, or legal
residency documents
*Please keep us current with monthly statements for banks, money market accounts, brokerage
accounts, etc.