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State of Maryland Medical Assistance Manual Revised April 2014
TRUST/DOCUMENT REVIEW REQUEST
To: Office of Eligibility Services
Date ________________ Department of Health and Mental Hygiene
201 W. Preston Street, Room SS-10
Baltimore, Maryland 21201
From: Local DSS: _____________________________________________________________
Case Manager Name: _____________________________________________________
Address: _______________________________________________________________
_______________________________________________________________________
Telephone: ____________________________ RE: Trust Documents Other: ________________________
Case Name: _____________________Case Number: ______________Date of Application:__________
Please review the attached documents and respond below:
Does the document represent a countable resource to this A/R?
Does the document represent a disposal of resources for less than fair market value?
Other information requested: _____________________________________________________________________________ ______________________________________________________________________________ _____________________________________________________________________________.
Date Response Needed: ________________________
[To Be Completed By Reviewer]
Initial OES Reviewer Name: __________________________ Telephone: _______________
Initial Reviewer Response: ____________________________________________________________________________________ ___________________________________________________________________________________ ___________________________________________________________________________________ ____________________________________________________________________________________
Additional Information Requested by Reviewer: Yes No Date Returned: ________________
Date Additional Information Requested: _____________
DES/LTC 814 Revised 10/13