Medicaid Form

Page 1

Name

First Name

Last Name

Name of the nursing home

Date Of Birth

Do you have Medicaid in the community?

Yes
No

What is your Medicaid ID #

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Address

What was your HOME address prior to admission?

Street Address

Address Line 2

City

State/Region/Province

Postal/Zip Code

Prior Facility

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Where you in a SNF or Assisted Living before coming here?

Yes

No

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SNF Prior

Address

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Spouse

Do you have a spouse?

Yes

Widowed in past 5 years

Divorced in past 5 years

Never married-single for the past 5 years

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Demographics

Please select all that apply:

Veteran

Have a disabled child living at home

Filed taxes in the past 4 years

Employment status Select Retired Unemployed Currently Working

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Real Estate and Vechicles

Do you currently or within the past 5 years, own a home (including a trailer home)?

Currently own

Renting

Sold/Transferred in the past 5 years

Living with someone rent free

Own a RENTAL PROPERTY (property I rent out)

any other land

How much is rent?

If you pay for water, how much is your monthly bill (write N/A if you do not)

What is the equity value of your home, less any mortgage

VEHICLE INFORMATION

Do you own, or did you sell, any vehicles in past 5 years? check all that apply.

Own

Sold

N/A

Make and Model

Fair market Value (based on Kelly Blue Book)

Date Sold

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Sold Property

PLEASE PROVIDE INFO ABOUT THE SALE

SALE OF HOUSE

	Address	Fair Value	Sale Price	Date Sold
Property 1
Property 2

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Insurance Info

Name of Homeowners insurance

CHECK ALL THAT APPLY

Have Medicare

Have Medicare Replacement (Like UHC Medicare)

Have insurance through work

Have Medigap insurance (i.e. AARP or Medex)n

Life Insurance (including through an annuity)

NONE

Medicare #

HMO Name and ID #

Life Insurance provider

Cash Value

Policy #

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Income

Next we will review your income:

YOUR INCOME

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INCOME INFORMATION

	Name of payer	Amount	Frequency
Social Security
Pension
Pension
Annuity
IRA distribution
Stock Dividends

TRUST INFO

	Trust name	Garantor	Trustee	Amount
TRUST

Spouse's Income

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INCOME INFORMATION

	Name of payer	Amount	Frequency
Social Security
Pension
Pension
Annuity
IRA distribution
Stock Dividends

SPOUSE TRUST INFO TRUST

	Trust name	Garantor	Trustee	Amount
TRUST

if you have a trust please provide the info

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Investments

Your Investments

	Company Name	Approx. Value
Stocks
Bonds
Annuity
IRA

Your Spouse Investments

	Company Name	Approx. Value
Stocks
Bonds
Annuity
IRA

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Banking

Your banking information

Do you have, or did you have in the past 5 years, any bank accounts?

YES No

Bank info

	Bank	Account #	$ Amount	Date closed
Bank #1
Bank #2
Bank #3

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Spouse banking

Now we will review your spouse banking information

Do you have, or did you have in the past 5 years, any bank accounts?

YES No

Bank info

	Bank	Account #	$ Amount	Date closed
Bank #1
Bank #2
Bank #3

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Funeral Info

Do you have an irrevocable prepaid burial setup?
YES No

	Name	Price
Funeral Home

Do you have an irrevocable prepaid burial setup for spouse?
YES No

	Name	Price
Funeral Home

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Spouses Name

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Best Contact

Name

First Name

Last Name

Email

Tenant Signature

Clear Signature

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