Medicaid application Form

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Video instructions and help with filling out and completing Medicaid application form

We will now continue on with this audiovisual piece and the supplement a application this second application is important because it provides us with all the resource information required for a chronic care case in order to determine full financial eligibility sections a through f must be completed by or for chronic care applicants and it must be signed and dated at the end on page six here put down the full legal name of the person who needs our financial medical assistance last name first name middle initial their social security number and their marital status the following questions can be answered by checking the yes or no box whichever one applies page one be blind disabled or chronically ill is the person named in Section A above chronically ill some examples of chronically ill would be someone who has been unable to work for at least 12 months because of illness or injury or having an illness or disabling impairment that has lasted or is expected to last for more than 12 months is the person named in Section a above certified blind by the Commission for the blind and visually handicapped if yes you must prproof if the person named in Section a above is disabled and working is he or she interested in applying for the Medicaid buying program for working people with disabilities this offers Medicaid coverage to people who are disabled working and at least 16 years old but not yet 65 years old page 1 see is the person named in Section a above living in an adult home or assisted living facility please check yes or no page two d resources and assets check the box that applies we need to clarify exactly what type of medical care you have currently or are seeking coverage for there are three different levels so please read each choice over carefully the first option allows you to attest to the amount of your resources it does not cover nursing home care or home care of any of the community-based long-term care services as described an option to below the second option will cover community-based long-term care coverage as listed on the application it will also cover some waiver services such as traumatic brain injury program and the long-term home care program if you choose this option you must document the amount of your current resources the third option is for those who are institutionalized and applying for coverage of nursing home care with this option you must pruse of all resources back to februari first 2022 or the past 60 months whichever is less please list all resources owned by you and/or your spouse or parents including custodial accounts in the spaces provided at the bottom of page to all of age three and the top of page four if applying for coverage of nursing home care this list should include any accounts closed since februari first 2022 or in the past.