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State of Maryland Medical Assistance Manual Revised April 2014

LTC – Request for Information to Verify Eligibility – Page 2 Case Name:

CID:

IV. ASSETS Checking, Savings, Certificate of Deposits, Stocks, Bonds, Mutual Funds, Trusts, LTC Insurance, etc; (for the month of application and any additional statements specified)

N/A OK NEED NAME

ACCT.# COMMENTS

(which months, etc.)

   _____________________ _____________________ ____________________    _____________________ _____________________ ____________________    _____________________ _____________________ ____________________    _____________________ _____________________ ____________________    _____________________ _____________________ ____________________    _____________________ _____________________ ____________________

Closed Accounts – final statement (accounts which were active/open at any time in the past 36 months) N/A OK NEED TYPE

ACCT.# COMMENTS

   _____________________ _____________________ ____________________    _____________________ _____________________ ____________________

Life Insurance – Form DES 2001, letter from the Insurance Company (stating original face value, current cash value, dividend value, loans against policy), or copy of policy with amortization table for current cash value

N/A OK NEED Company Name

Policy Number    _______________________________ ________________________________    _______________________________ ________________________________

Home Property/Other Property N/A OK NEED Primary/other: _________________________________________________     Mortgage Agreement  DHMH 4255 Physician’s Report  Deed(s)     State Property Tax Assessment  DHMH 4255 Statement of Intent

Funeral Arrangements N/A OK NEED    Bank Account Statements/Irrevocable and Itemized Contracts: ______________

________________________________________________________________ V. ALLOWANCES Health Insurance N/A OK NEED    Other Health Insurance (ID card – front and back, actual premium bill or cancelled check) Residential Allowance N/A OK NEED    DHMH 4245 Physician’s Report Spousal Allowance    Income and Expense Reporting Form for Community Spouse

 ADDITIONAL INFORMATION NEEDED (see attachment)

When I sign below it means I understand I must provide the information and verifications checked on this form. I may have to provide additional documentation, if indicated in the review of the material I provide. I understand this application is good for only six months from the date I applied and I will have to file a new application if I do not provide all required verification in that time period.

_______________________________________

SIGNATURE DHR/FIA 1052-LTC Page 2 (Revised 12/08) White – Customer copy

Yellow – Long Term Care Facility Copy

Pink – Case Record Copy