60-Month Checklist for Medicaid

MEDICAL ASSISTANCE APPLICATION CHECKLIST

Date:_______________________________________________________________________

Client/Contact:

Medical Assistance for:

Eligibility for Medical Assistance is determined on the basis of both the medical needs and financial eligibility. We understand that all items listed below may not pertain to your particular situation. Please gather all items which do pertain. Before the Department of Social Services (DSS) can process your application for Long Term Care, the following items must be mailed or brought into our office:

I. BASIC REQUIREMENTS Required Provided

Application (We have and will complete) ________ ________

DHMH Form #257 (Nursing Home to Provide) ________ ________

DES 2005 Consent for Release of Information ________ ________

(We have for client to sign)

DHMH 4245 Physicians Report (Physician to Provide) ________ ________

II. PERSONAL VERIFICATIONS Required Provided

Social Security Card _______ ________

Medicare Card _______ ________

Power of Attorney _______ ________

Marriage Certificate _______ ________

Death Certificate for deceased spouse _______ ________

Citizenship status documentation _______ ________

Alien registration card _______ ________

Visa _______ ________

Birth Certificate _______ ________

Voter Registration ________ ________

Private Health Insurance ________ ________

ID Card ________ ________

Verification of any premiums paid ________ ________

Copy of last paid Nursing Home Bill ________ ________

III. RESOURCE VERIFICATIONS Please provide statements for all accounts owned within the previous five years (60 months), regardless of whether account is now closed. DSS will required an explanation for any and all transactions over $500. Please provide copies of checks and/or documentation and an explanation for any such transaction.

Required Provided

Savings Account ________ ________

Checking ________ ________

Brokerage Accounts/CDs/IRAs ________ ________

Stocks & Bonds (copies of certificates & bonds;

Documentation re: name, amount, and value) ________ ________

Trust Funds ________ ________

Investments ________ ________

Retirement Accounts ________ ________

Annuities ________ ________

Life Insurance ________ ________

Policy statements ________ ________

Current face and cash values _______ _______

Burial Account ________ ________

Pre-paid irrevocable contract ________ ________

Deed for plots ________ ________


Real Property ________ ________

Deed ________ ________

Statement of Intent ________ ________

Tax Assessment ________ ________

Mortgage Agreement ________ ________

Lien information ________ ________

Other______________________________ ________ ________

Other______________________________ ________ ________

IV. INCOME VERIFICATIONS Required Provided

Social Security Award Letter (yearly benefit amt) ________ ________

Civil Service Annuity Award Letter (yearly benefit amt) ________ ________

Pensions: current gross monthly amount ________ ________

Last 5 years of Income Tax Returns ________ ________

Other_____________________________________ ________ ________

Other_____________________________________ ________ ________


V. SPOUSAL ALLOWANCES Required Provided

Gas and Electric Bills (3 months worth) ________ ________

Rent ________ ________

Homeowners Insurance ________ ________

Heat ________ ________

Mortgage Payment ________ ________

Water

________ ________

Property Taxes _______ ________

Community spouse's gross monthly income ________ ________

***PLEASE NOTE that you will need to provide updated monthly statements to our office for each account up until the date your application is filed.

I have read the above Checklist and understand what documents and information I am required to provide, including the need to update documents, as well as provide documentation, verification, and explanations of any transactions over $500.00

______________________________ _____________________________Date Client

QUESTIONS?

Please call the Law Office of Scott Alan Morrison, P.A.

Frederick – 301-694-6262

Hagerstown – 301-293-0010