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1. Who is filling out this form? *

The applicant (person who needs Medicaid)

A friend or family member

A legal guardian or power of attorney

A professional (social worker, attorney, etc.)

2. Who is applying for Medicaid? *

Myself

My spouse

My parent(s)

My grandparent(s)

A client

3. What is the applicant's marital status? *

Income and assets are counted differently for couples vs. single applicants.

Single

Married

Widowed

Divorced or separated

4. Where does the person applying for Medicaid currently reside? *

At home

In a friend or family member's home

In assisted living

In temporary rehab

In a nursing home permanently

5. What is the age of the person applying for Medicaid? *

Medicaid has different eligibility rules depending on the age of the applicant.

Under 65 and not disabled

Under 65 and disabled & receiving SSDI

65-85

Over 85

6. What is the primary reason for applying for Medicaid? *

Different eligibility criteria apply for nursing home vs. home care.

Paying for nursing home care

Paying for assisted living

Covering in-home care costs

Planning ahead before care is needed

7. Is the person applying a veteran OR the widow / widower of a veteran? If so, did they serve during wartime? *

Applicants may also be eligible for VA benefits which could exceed the benefits of Medicaid.

Non-wartime veteran / spouse

Wartime veteran / spouse

Not a veteran

9. Is the applicant considering applying for Medicaid in a different state?

Yes

No

10. What benefits and / or coverage does the person applying for Medicaid currently have? Check all that apply.

In some instances, applying for or receiving Medicaid can jeopardize current benefits.

Medicare / Medicare Advantage

Long Term Care Medicaid

Regular (ABD) Medicaid

Veterans Pension

Social Security Disability (SSDI)

Supplemental Security Income (SSI)

None of the above

11. How soon do you anticipate the need for Medicaid?

The application and approval process can be time-consuming but can also be expedited.

Need it ASAP -- paying for care right now

Need it within the next 3-6 months

Just planning ahead, no immediate need

Your Name

The name of the person filling out this form (not necessarily the Medicaid applicant)

First Name

Last Name

Your phone number

(###)

###

####

Best time to contact you?

Morning

Afternoon

Anytime

Best way to contact you?

Phone call

Text message

Email