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 – 301-732-7669
