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State of Maryland Medical Assistance Manual Revised April 2014

MARYLAND DEPARTMENT OF HUMAN RESOURCES Family Investment Administration Long Term Care Medical Assistance Request for Information to Verify Eligibility

Ms./Mr. _________________________________ for ______________________________________

After you give us a signed application, we have 30 days to make a decision about eligibility for Long Term Care Medical Assistance. To make that decision, we must have the verifications checked NEED. Please mail or bring them to our office at the address above by __________________________________. Questions? Call your case manager at the number above.

Key: N/A – Not Applicable OK – Already have or do not need NEED – Please provide

I. BASIC REQUIREMENTS N/A OK NEED    Signed, dated application (DHR/FIA CARES 9709)    Face-to-Face Interview    Consent to Release Information – nursing home to DSS worker (DES 2002 form)    Consent to Release Information – DSS worker to nursing home (DES 2005 form)    Voter Registration Form 784    DHMH 257 (Medical certification initiated by Nursing Home) II. DEMOGRAPHIC DATA N/A OK NEED    Proof of Social Security Number (SSA 1099, SSA letter, or other SSA verification)    Medicare card    Alien status (alien registration card passport)    Proof of disability (DHMH 4204, DHR/FIA 402B, DHR/FIA 161 – for applicants 21-64 years old who have not been determined blind or disabled by the US. Social Security Administration)    Marriage Certificate/Divorce decrees III. MONTHLY INCOME N/A OK NEED    Social Security Benefits (award letter, 1-800-772-1213)    Private Pension (gross benefit/deductions, if any)    Application for any private/public benefit which the applicant may be entitled    Other (annuities, alimony, royalties, income from loans, etc.) _____________________

(PLEASE GO TO PAGE 2)

DHR/FIA 1052-LTC Page 1 (Revised 12/08) White – Customer copy

Yellow – Long Term Care Facility Copy

Pink – Case Record Copy

Copy also to: _________________________________ at ________________________________________________________

Local Department

Address:

Date:____________________________________

Case Name:_______________________________

Address:_________________________________

__________________________________

CID#:____________________________________ (Please use this number on all correspondence)

Case Manager:____________________________

Telephone Number:________________________