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State of Maryland Medical Assistance Manual Revised April 2014

MARYLAND MEDICAL ASSISTANCE PROGRAM HOME EXCLUSION – STATEMENT OF INTENT

Date: ____________________ PART I. INSTITUTIONALIZED PERSON’S IDENTIFICATION (To be completed by the Local Department of Social Services)

1. __________________________________________ _____________________________

Name

Client ID 2. ________________________________________

____________________________

Name of Facility

Telephone Number

Address 3. ___________________________________________ ____________________________ Representative’s Name

Telephone Number

Address

4.

Case Manager Department of Social Services

Telephone Number

Address

PART II. STATEMENT OF INTENT TO RESUME LIVING IN HOME PROPERTY

Read this entire section before answering the question below. The person’s representative may answer the question.

If “no” is checked, the equity value of the person’s home may be a countable resource which could cause the person to be ineligible for Medical Assistance. If “yes” is checked, the person’s home property will not be a countable resource; however, the State may place a lien on the home and other real property.

Does the institutionalized person ever intend to live in his/her home property located at ___________________________________________________________________________________ again?

Yes No

Signature of Applicant or Representative ___________________________________ Date _______________

DHMH 4255 (LTC) Revised 12/08