Medicaid Questionnaire

MEDICAID FOR NEW YORKERS

Medicaid requires your information & documentation to process an application.

To make this process as efficient as possible, and to enable you to provide much of the information from the comfort of your home (or phone), we encourage you to complete our Medicaid questionnaire.

Please note that the questionnaire only asks for information that Medicaid requires.

Please skip any field that does not apply to you.

Please fill out these details:

Applicant's First Name*

Applicant's Last Name*

Caretaker's First Name (Person 'In charge of Applicant')

Caretaker's Last Name

Caretaker's Relationship to Applicant

Caretaker's Last Name

Caretaker's Primary Phone Number

1 - Applicant Date of Birth

2 - Applicant City, State and Country of Birth

3 - Applicant Marital Status*

4 - Full Maiden Name (birth name before marriage) - "Enter (N/A) if not applicable"

5 - Applicant Soc Sec #

6 - Applicant Current Address

7 - Applicant Primary Phone Number

8 - Does Applicant have MediCARE?

9 - Applicant's Supplemental Health Insurance Company (Medigap (Medicare Suppl.) Policies, such as UnitedHealthcare, etc.)

10 - Monthly Premium for Supp Health Ins (Enter -0- if none or TBD if unknown (other than Medicare))

11 - Medicare Part D Prescription Drug Plan (List name of Insurance Co. Enter N/A if no Part D Plan)

12 - Monthly Premium for Prescription Drug Plan (Enter -0- if none or TBD if unknown)

13 - Physician (for Disability Determination) (Name & Contact Info of Primary ("Main") Physician)

14 - Salaries, Wages, Commissions (Total combined, if more than one. Enter "0" if none)

15 - Self-Employment Income (Total combined, if more than one. Enter "0" if none)

16 - Pension Income (Total combined, if more than one. Enter "0" if none)

17 - IRA Required Minimum Distributions (Per Month. Enter "0" if none)

18 - Annuity Income/Distributions (per month) (Total combined, if more than one account. Enter "0" if none)

19 - Dividends and/or Interest (total, per month) Total combined, if more than one. Enter "0" if none

20 - Social Security Pension Income (Per Month. Enter "0" if none)

21 - Social Security Supplemental Income (Per Month. Enter "0" if none)

22 - Social Security Disability Income (Per Month. Enter "0" if none)

23 - Rental Income (Total per month. Enter "0" if none.)

24 - Checking Account Balance (Total combined, if more than one account. Enter "0" if no account)

Number of Checking Accounts (Select the number of accounts)

25 - Savings Account Balance (Total combined, if more than one account. Enter "0" if no account)

Number of Savings Accounts (Select the number of accounts)

26 - IRA Current Balance (Total combined, if more than one account. Enter "0" if no account)

Number of IRA Accounts (Select the number of accounts)

27 - IRA-Roth Current Balance (Total combined, if more than one account. Enter "0" if no account)

Number of IRA-Roth Accounts (Select the number of accounts)

28 - CD(s) Current Balance (Total combined, if more than one account. Enter "0" if no account)

Number of CDs (Select the number of accounts)

29 - Annuity Current Balance (Total combined, if more than one annuity. Enter "0" if no annuity)

Number of Annuities (Select the number of annuities)

30 - 401k Current Balance (Total combined, if more than one account. Enter "0" if no account)

Number of 401k Accounts (Select the number of accounts)

31 - Brokerage Account Current Balance (Total combined, if more than one account. Enter "0" if no account)

Number of Brokerage Accounts (Select the number of accounts)

32 - Bonds Current Balance (Total combined, if more than one account. Enter "0" if no account)

33 - Stocks Current Balance (Total combined, if more than one account. Enter "0" if no account)

34 - Trust Asset(s)'s Value (Total combined asset(s) owned by Trust created by or for you. Enter "0" if none)

Number of Assets titled to Trust (Select the number of assets owned by Trust)

35 - Trust Income (payable to applicant or spouse) (Total monthly trust income. Enter "0" if none)

36 - Rent to Landlord (monthly) (Enter "0" if Applicant doesn't pay rent)

37 - Primary Residence, Net Equity Value (Value of your home, less mortgage. Enter "0" if none)

38 - Real Estate Investment, Net Equity Value (Value of Real Estate Investm/Vacation Home, excl. Primary Residence)

39 - Mortgage Payment (monthly) (Enter "0" if none)

40 - Property Taxes (monthly) (Enter "0" if Applicant doesn't own real estate)

41 - Water Payment (monthly) (Enter "0" if none)

42 - Life Insurance CASH Value(s) (Total combined, if more than one policy. Enter "0" if no policy)

Number Life Insurance Policies (Select the number of policies)

43 - Car: Owner & Year/Make/Model & Value (Enter "N/A" if not applicable)

44 - Value of Business, Partnerships, LLCs, etc. (Total combined value, if more than one. Enter "0" if none)

Total Number of Businesses, Partnerships, LLCs, etc. (State in how many companies / businesses you own an interest)

45 - Prior Gifts/Transfers for less than FMV (Only for Nursing Home Medicaid App. Prior Gifts/Transf. in last 60 months (2K+). Enter "0" if none.)

47 - Do you want to protect your home against potential liens or estate recovery by NYS, etc.? ()

Please state here any other issues & concerns you would like us to discuss or be aware of

Spouse Full Name

Spouse First name

Spouse Last Name

Spouse Primary Phone Number

48 - Spouse Date of Birth

49 - Spouse's City, State and Country of Birth

50 - Spouse Full Maiden Name (birth name before marriage)

51 - Spouse's Soc Sec #

52 - Spouse Current Address

53 - Does Spouse have MediCARE

54 - Spouse Supplemental Insurance (Medigap (Medicare Suppl.) Policies, such as UnitedHealthcare, etc.)

55 - Spouse Monthly Premium for Supp Health Ins (Enter -0- if none or TBD if unknown (other than Medicare))

56 - Spouse Medicare Part D Prescription Drug Plan (List name of Insurance Co & monthly premium. Enter N/A if no Part D Plan)

57 - Monthly Premium for Prescription Drug Plan (Enter -0- if none or TBD if unknown)

58 - Spouse's Physician (for Disability Determination) (Name & Contact Info of Primary ("Main") Physician)

59 - Spouse Salaries, Wages, Commissions (Total combined, if more than one. Enter "0" if none)

60 - Spouse Self-Employment Income (Total combined, if more than one. Enter "0" if none)

61 - Spouse Pension Income (Total combined, if more than one. Enter "0" if none)

62 - Spouse IRA Required Minimum Distributions (Per Month. Enter "0" if none)

63 - Spouse Annuity Income/Distributions (per month) (Total combined, if more than one account. Enter "0" if none)

64 - Spouse Dividends and/or Interest (total, per month) (Total combined, if more than one. Enter "0" if none)

65 - Spouse Social Security Pension Income (Per Month. Enter "0" if none)

66 - Spouse Social Security Supplemental Income (Per Month. Enter "0" if none)

67 - Spouse Social Security Disability Income (Per Month. Enter "0" if none)

68 - Spouse Rental Income) (Total per month. Enter "0" if none)

69 - Spouse Checking Account Balance (Total combined, if more than one account. Enter "0" if no account)

Number of Checking Accounts (Select the number of accounts)

70 - Spouse Savings Account Balance (Total combined, if more than one account. Enter "0" if no account)

Number of Savings Accounts (Select the number of accounts)

71 - Spouse IRA Current Balance (Total combined, if more than one account. Enter "0" if no account)

Number of IRA Accounts (Select the number of accounts)

72 - Spouse IRA-Roth Current Balance (Total combined, if more than one account. Enter "0" if no account)

Number of IRA-Roth Accounts (Select the number of accounts)

73 - Spouse CD(s) Current Balance (Total combined, if more than one account. Enter "0" if no account)

Number of CDs (Select the number of CDs)

74 - Spouse Annuity Current Balance (Total combined, if more than one annuity. Enter "0" if no annuities)

Number of Annuities (Select the number of annuities)

75 - Spouse 401k Current Balance (Total combined, if more than one account. Enter "0" if no account)

Number of 401k Accounts (Select the number of accounts)

76 - Spouse Brokerage Account Current Balance (Total combined, if more than one account. Enter "0" if no account)

Number of Brokerage Accounts (Select the number of accounts)

77 - Spouse Bonds Current Balance (Total combined, if more than one account. Enter "0" if no account)

78 - Spouse Stocks Current Balance (Total combined, if more than one. Enter "0" if none)

79 - Spouse Trust Asset(s)'s Value (Total combined assets owned by Trust created by or for you. Enter "0" if none)

Number of Assets titled to Trust (Select the number of assets owned by Trust)

80 - Spouse Trust Income (payable to applicant or spouse) (Total monthly trust income. Enter "0" if none)

81 - Spouse Rent to Landlord (monthly) (Enter "0" if spouse does not pay rent)

82 - Spouse Primary Residence, Net Equity Value (Value of your home, less mortgage. Enter "0" if none)

83 - Spouse Real Estate Investment, Net Equity Value (Value of Real Estate Investm/Vacation Home, excl. Primary Residence)

84 - Spouse Mortgage Payment (monthly) (Enter "0" if none)

85 - Spouse Property Taxes (monthly) (Enter "0" if spouse doesn't own real estate)

86 - Spouse Water Payment (monthly) (Enter "0" if none)

87 - Spouse Life Insurance CASH Value(s) (Total combined, if more than one policy. Enter "0" if no policies)

Number Life Insurance Policies (Select the number of policies)

88 - Spouse Car: Owner & Yr/Make/Model & Value (Enter "N/A" if not applicable.)

89 - Spouse Value of Businesses, Partnerships, LLCs, etc. (Total combined, if more than one. Enter "0" if none)

Total Number of Businesses, Partnerships, LLCs (State in how many companies / businesses you own an interest)

90 - Spouse: Prior Gifts/Transfers for less than FMV (Only for Nursing Home Medicaid App. Prior Gifts/Transf. in last 60 months (2K+). Enter "0" if none)

92 - Do you want to protect your home against potential liens or estate recovery by NYS, etc.?

Medicaid Questionnaire

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