Medical Assistance (Medicaid) Intake Form

We will manage the application process.

Contact Information
Name*
First Last
Address*
Street Address City State ZIP Code
Phone*
Relationship*
Email*
Appointed POA or Guardian
Applicant
Name*
First Last
Address*
Street Address City State ZIP Code
Phone*
Marital Status
If married, please complete form again for spouse.
Date of Birth*
Date Format: MM slash DD slash YYYY
Current Location
Please indicate the applicant's current location, and fill out any information that applies.
Residence
Assisted Living
Hospital
Nursing Home
Nursing Home - Date of Admission
Date Format: MM slash DD slash YYYY
Other
Medical Insurance
Primary Coverage
Secondary Coverage
Financial Information
Does Resident have pre-paid irrevocable funeral?
- Yes
- No
Does Resident own any real estate?
- Yes
- No
Does Resident own Life Insurance Policies?
- Yes
- No
Does Resident have any unpaid debts?
- Yes
- No
Does Resident have a child who has lived with him/her for 2 or more years prior to entering nursing home?
- Yes
- No
Has Resident made any gifts of $500 or more in a month within the last 5 years?
- Yes
- No
Does Resident have a blind or disabled child?
- Yes
- No
Bank Accounts
Type Present Value
Investment Accounts
Type Present Value
IRA's
IRA Present Value
Life Insurance
Company Face Value Cash Value
Income Sources
Please enter dollar amount.
Social Security
Pension
Railroad
VA
Black Lung
Other

Type	Present Value

Type	Present Value

IRA	Present Value

Company	Face Value	Cash Value