APPLICATION FOR MISSISSIPPI MEDICAID MEDICAL HOME S AGED, BLIND OR DISABLED PROGRAM

Transcription

1 APPLICATION FOR MISSISSIPPI MEDICAID MEDICAL HOME S AGED, BLIND OR DISABLED PROGRAM Please read each question carefully before answering. The answers given will determine whether or not the person(s) applying will be eligible for Medicaid. A friend or relative may help the applicant complete this form. A Medicaid worker is also available if any help is needed. Just contact your local Medicaid Regional Office. If you or your spouse are blind or hearing impaired, please indicate so that any special needs you may have can be evaluated: Blind Hearing Impaired WHEN THE FORM IS COMPLETED AND SIGNED, YOU SHOULD EITHER MAIL, FAX, OR BRING IT TO YOUR MEDICAID REGIONAL OFFICE AT THE FOLLOWING ADDRESS: For Medicaid Regional Office Use Only Worker Date Interviewed/Received PLAD QMB Only SLMB Hospice HCBS Disabled Child QWDI SSI Only LTC Nursing Home/Hospital Case Name Case Number Spouse Name Case Number Rights and Responsibilities explained at time of interview? Yes No Pamphlets given at time of interview P1 P2 P3 P4 P5 P6 HCBS DOM 300 REVISED 3/31/2005

2 INSTRUCTIONS - Read the application carefully and follow all instructions given throughout this form. Include copies of all documents. Do not send original documents. PERSONAL INFORMATION: NAME: Last Name First Name Middle Initial Maiden Name SOCIAL SECURITY NUMBER: BIRTHDATE: / / MARITAL STATUS: Single Married Separated Divorced Widowed Home Telephone Number: ( ) Message # ( ) SEX: Male RACE: White Black American Indian/Alaskan Native Female Hispanic Asian Pacific Islander/Native Hawaiian Other SPOUSE INFORMATION: (Provide information even if spouse is not applying or is deceased.) NAME: Date of Death or Divorce: Does your spouse want to apply for Medicaid? Yes No OTHER INFORMATION: Last Name First Name Middle Initial Maiden Name SOCIAL SECURITY NUMBER: BIRTHDATE: / / (Required only if spouse is applying) SEX: Male RACE: White Black American Indian/Alaskan Native Female Hispanic Asian Pacific Islander/Native Hawaiian Other What is the primary language spoken in your home (if other than English)? Do you need an English interpreter? Yes No Are you and your spouse (if applying) both U.S. Citizens? Yes No If No are you lawfully admitted for permanent residence? Yes No If under the age of 65, what is your disability? If under the age of 65, what is your spouse s disability (if applying)? Please tell us where you live. In own home With family and friends Currently in a hospital In a nursing home Other (please specify) Do you plan to remain in Mississippi? Yes No What is your mailing address? Street Address or P.O. Box City County State Zip What is the address where you live, if different from your mailing address? Street Address or P.O. Box City County State Zip List all of the people that live in your household other than you and your spouse: Name Age Relationship

3 Are you or your spouse a veteran? Yes No If Yes give the following information: Name of Veteran Relationship Branch of Service Dates of Service RETROACTIVE MEDICAID: Medicaid may be able to cover you in the 3 months prior to the date of this application or the date the application was filed for SSI if you are eligible and received services covered by Medicaid during the three (3) month retroactive period. Do you want to apply for retroactive Medicaid? Yes No Does your spouse want to apply for retroactive Medicaid? Yes No MEDICARE AND OTHER HEALTH INSURANCE INFORMATION: Do you have Medicare? Yes No If Yes Medicare Claim # Type of coverage: Part A? Yes No Part B? Yes No Does your spouse have Medicare? Yes No If Yes Medicare Claim # Type of coverage: Part A? Yes No Part B? Yes No Do you or your spouse have any other health insurance? Yes No If Yes complete the following: Insured Insurance Company Policy Number Effective Date Self Spouse RESOURCES - These are the things that you and/or your spouse currently own or are buying. Do you own or are you buying a home? Yes No If yes, Location: Do you own or are you buying any other property? Yes No If yes, Location: Do you own or are you buying any vehicles (car, truck, motorcycle, boat, trailer, etc)? Yes No List the information below for each vehicle you have: Make of Vehicle Model of Vehicle Year Amount owed on vehicle (Chev.,Ford, etc.) (Impala, Escort, etc.) Does your name appear on any bank accounts? Yes No If Yes, list ALL bank accounts (checking, savings, safe deposit boxes, etc.) that have your name and/or your spouse s name listed as a single or joint owner. (We will need a copy of the latest bank statement on each account.) Name on the Acct. Type of Acct. Acct. Number Amount Name of Bank

4 Do you or your spouse own or are you buying life insurance and/or burial insurance policies? Yes No If Yes, list ALL life insurance and/or burial insurance policies Type of Policy Insurance Company Policy # Amt. Of Insurance Is there anything else you have or are buying that has not already been listed?? Yes No If Yes, list ALL Item Owned Value Owner Have you transferred or given away any assets (money, property, etc.) to someone else within the last three (3) years? Yes No If Yes, please explain: INCOME AND EARNINGS: Do you receive any money (income) each month? Yes No If Yes complete the following: List all types of earnings and income that you and/or your spouse receive. List the income amounts before deductions (such as taxes or insurance) are taken out. Include proof of all income (check stub, benefit letter, etc.) Do not send original documents. Examples of income include: * Social Security * Railroad Retirement Benefits * Pensions/Retirement Benefits * SSI * Veteran s Benefits * Rental Income * Oil Royalties/Mineral * Interest from CD s, Savings Acc t.,etc. * Unemployment Name on the Check Source of income (SSA, VA, etc.) Amount How Often Received? Claim If from wages list Employer. (monthly, quarterly) If Number wages, what day paid?

5 PRIVACY ACT and COMPUTER MATCHING NOTICE: The Division of Medicaid is authorized to request the information on this form. The primary use of this information is to determine eligibility for Medicaid and is protected by law from disclosure to unauthorized persons. It is possible that this form may be used to determine another person s right to Medicaid benefits. Also, to comply with federal law, the applicant s Social Security Number (s) will be computer matched with other agencies, such as the Social Security Administration and the Internal Revenue Service, to obtain information about income and resources available to the applicant. These matches may also be done on an individual basis. ASSIGNMENT OR RIGHTS TO THIRD PARTY PAYMENT, COOPERATION REQUIREMENT & ESTATE RECOVERY REQUIREMENT * Medicaid does not pay medical expenses that a third party, such as a private health insurance company, is supposed to pay. All persons applying for Medicaid benefits are required to assign the Division of Medicaid any rights they may have to medical support or other third party payments for medical care. When you sign this application for Medicaid benefits, you are assigning the Division of Medicaid all rights to collect or receive any such payments for the time you are (were) on Medicaid. * Information you give is confidential. Your medical information can only be released if needed to administer the Medicaid programs. If you receive care or treatment under Medicaid, you authorize the health care provider to release to Medicaid, your medical records and information relating to your diagnosis, examination and treatment. The Notice of Privacy Practices is available from your Regional Office. This notice describes how medical information about you may be used and disclosed how you get access to this information. * I (we) understand that by applying for Medicaid benefits I (we) agree to cooperate with the DIVISION OF MEDICAID in identifying and providing information to help pursue any third party who may be responsible for providing medical support for me (us). If I (we) am/are signing this application on behalf of another person, I We agree to cooperate in identifying and obtaining information to pursue any third party who may be responsible for providing medical support for them. * I (We) understand that if I (we) am/are eligible to enroll in any insurance or benefits plan offered by my employer or my spouse s employer, I m required to enroll in that plan. * I (We) understand that upon my/our death, the Division of Medicaid has the legal right to seek recovery from my estate for services paid by Medicaid in the absence of a legal surviving spouse or a legal surviving dependent. Consideration will be made for hardship cases. An estate consists of real & personal property. Estate recovery applies to nursing homes, home and community based waiver clients age 55 or older. APPLICANT S RESPONSIBILITIES * I know that anyone who makes or causes to be made a false statements or misrepresentation of material in an application or for use in determining eligibility for Medicaid commits a crime punishable by federal and/or state law. I affirm that all information given in this document or in support of it is true. * If this application or other information shows that the recipient may be eligible for any payments or benefits form other sources, the applicant is required to file for other benefits when notified be the DIVISION OF MEDICAID. * The Medicaid Regional Office must be notified immediately if there is a change in the applicant s address, living arrangements, family size, income or resources. Also, the Regional Office must be notified if the recipients is discharged from a hospital or nursing home or if the client moves from one medical facility to another. * If this application is for someone who is blind or disabled, the Regional Office must be notified of any improvement in the recipient s medical condition or if the recipient returns to work. * The recipient s case may be selected for quality control purposes in state and/or federal review. If his/her case is selected, the applicant s full cooperation is required. Does the applicant(s) and/or designated representative accept these responsibilities and agree to notify the Medicaid office of any changes listed above? Yes No Signature of Applicant or Designated Representative Date Telephone Number Signature of Spouse if applying or Designated Representative Date Telephone Number Address of Designated Representative The Division of Medicaid complies with all State and Federal policies which prohibit discrimination on the basis of race, age, sex, national origin, handicap or disability as defined through The American with Disabilities Act of 1990.