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State of Maryland Medical Assistance Manual Revised April 2014

MARYLAND MEDICAL ASSISTANCE PROGRAM NOTICE TO REVIEW MEDICAL ASSISTANCE ELIGIBILITY FOR SSI LONG TERM CARE

Date:_________________________ RE: __________________________

Client ID #: ____________________

Dear ____________________________________:

This is to notify you that it is time to review Medical Assistance eligibility for the above-named recipient. Please answer fully the questions below: 1. Does the recipient still reside in a nursing home? □ Yes (go to #3) □ No (go to #2)

2. What was the date of discharge or death? ___/____/____(Please stop here and return this form to the local department. If deceased, please send a copy of the death certificate.)

3. What is the name of that nursing home? _______________________________________

4. Who is the recipient’s current authorized representative?

Name: _________________________________ Relationship:______________________

Address: __________________________________________________________________

__________________________________________________________________

Home Phone: __________________________ Other Phone:________________________

5. What kind of income does the recipient receive? (Please attach proof(s) of income) □ SSI □ SSDI □ Veteran’s □ Other___________________________ 6. What assets does the recipient own? (bank accounts, life insurance, property, etc.) (Please attach proof(s) of income) □ _________________________________ □ _________________________________ □ _________________________________ Please return photocopies of those items with this letter to the local department before ______________. All Medical Assistance recipients are required to report to their caseworker any changes concerning their circumstances within 10 business days of the change. This includes, but is not limited to, changes in income, resources, living arrangements, and home property. Sincerely,

________________________________ Case Manager

________________________________ Department of Social Services

________________________________

Telephone Number

DHMH 4241A (SSI/LTC) – Revised 12/08

White–Customer/Authorized Representative Copy Yellow-Long Term Care Facility Copy Pink-Case Record Copy