Medicaid Form
Page 1
Name
First Name
Last Name
Name of the nursing home
Please input the name of the Nursing Home
Date Of Birth
Do you have Medicaid in the community?
Yes
No
What is your Medicaid ID #
Next
Address
What was your HOME address prior to admission?
Street Address
Address Line 2
City
State/Region/Province
Postal / Zip Code
Please enter your home address
Prior Facility
Where you in a SNF or Assisted Living before coming here?
Yes
No
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Next
SNF prior
Address
Street Address
Address Line 2
City
State/Region/Province
Postal / Zip Code
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Next
Spouse
Do you have a spouse?
Yes
Widowed in past 5 years
Divorced in past 5 years
Never married
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Next
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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Next
Real Estate and Vechicles
Do you currently or within the past 5 years, own a home (including a trailer home)?
Currently own
Renting
Filed taxes in the past 4 years
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
Property 1
Address
Fair Value
Sale Price
Date Sold
Property 2
Address
Fair Value
Sale Price
Date Sold
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Insurance Info
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
INCOME INFORMATION
Social Security
Name of payer
Amount
Frequency
Pension
Name of payer
Amount
Frequency
Pension
Name of payer
Amount
Frequency
Annuity
Name of payer
Amount
Frequency
IRA distribution
Name of payer
Amount
Frequency
Stock Dividends
Name of payer
Amount
Frequency
TRUST INFO
TRUST
Trust name
Garantor
Trustee
Amount
if you have a trust please provide the info
Spouse's Income
INCOME INFORMATION
Social Security
Name of payer
Amount
Frequency
Pension
Name of payer
Amount
Frequency
Pension
Name of payer
Amount
Frequency
Annuity
Name of payer
Amount
Frequency
IRA distribution
Name of payer
Amount
Frequency
Stock Dividends
Name of payer
Amount
Frequency
Spouse's TRUST INFO
TRUST
Trust name
Garantor
Trustee
Amount
if you have a trust please provide the info
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Next
Investments
Your Investments
Stocks
Company Name
Approx. Value
Bonds
Company Name
Approx. Value
Annuity
Company Name
Approx. Value
IRA
Company Name
Approx. Value
Please checkoff all applicable items
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Banking
Now we will review your banking information
Do you have, or did you have in the past 5 years, any bank accounts?
YES
No
Bank info
Bank #1
Bank
Account #
$ Amount
Date closed
Bank #2
Bank
Account #
$ Amount
Date closed
Bank #3
Bank
Account #
$ Amount
Date closed
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Next
Spouse banking
Now we will review your banking information
Do you have, or did you have in the past 5 years, any bank accounts?
YES
No
Bank info
Bank #1
Bank
Account #
$ Amount
Date closed
Bank #2
Bank
Account #
$ Amount
Date closed
Bank #3
Bank
Account #
$ Amount
Date closed
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Funeral Info
Do you have an irrevocable prepaid burial setup?
YES
No
Info
Funeral Home
Name
Price
Do you have an irrevocable prepaid burial setup?
YES
No
Info
Funeral Home
Name
Price
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Spouses Name
Name
First Name
Last Name
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Best Contact
Name
First Name
Last Name
Email
Tenant Signature
Clear Signature
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Submit