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Medicaid Document Checklist

Please provide copies of the documents & statements that apply to you.  You may submit the paperwork in person, via email at info@mazloumi.com or via fax at 516-283-0250. And call us at 516-466-PLAN if you have any questions.

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  • Proof of Age
  • US Passport
  • Birth Certificate
  • Driver's License
  • Baptismal Certificate
  • Proof of Citizenship
  • US Passport
  • Birth Certificate
  • Naturalization Papers
  • Alien Registration Card
  • Final Adoption Decree
  • Identity
  • US Passport
  • Photo License
  • School ID
  • US Military ID
  • County ID
  • Marital Status
  • Marriage Certificate
  • Separation Papers
  • Divorce Papers
  • Spouse's Death Certificate
  • Financial Resources
  • Checking Account Statements
  • Money Market Accounts
  • Savings Account Statements
  • Certificates of Deposit (CDs) Statement
  • Brokerage Account Statement
  • Stocks or Bonds
  • Annuities
  • IRA Statement
  • 401K and 403B Statement
  • Automobile: Make/Model and Value
  • Deed (for personal residence, investment real estate, land, etc.)
  • Share Certificate (for Co-Ops)
  • Mortgages
  • Life Insurance Policy (+ Cash Value)
  • Burial Plot Information
  • Prepaid Funeral Contracts
  • Other Investments (such as LLCs, Partnerships, Corporations, etc.)
  • Income
  • Most Recent Pay Stubs
  • Social Security Award Letter
  • Railroad Retirement Award Letter
  • Dividend and Interest Income
  • Pension Statement (incl. Foreign Pensions)
  • Unemployment Check Stubs
  • Support / Alimony Checks or Court Order
  • RMD Statement (for IRAs)
  • Unemployment Check Stubs
  • Rental Income
  • VA award Letter
  • SSI Award Letter
  • Annuity Income
  • “Other” Investment Income
  • Tax Return (Incl. Business Tax Return)
  • W-2, K1S, 1099
  • Other
  • Social Security Card (Front & Back)
  • Medicare Card (Front & Back)
  • Water Bill
  • Property Tax Bill
  • Supplemental Health Insurance Card (+ Premium Statement)
  • Prescription Drugs Card (+ Premium Statement)
  • Power of Attorney and Health Care Proxy
  • Mortgage Statement
  • Lease or Rent Receipt (if renting)
  • Name and Contact Information of Treating Physician(s)
  • Medical Records

THE FOLLOWING LIVING EXPENSES WILL BE TAKEN INTO ACCOUNT IF THE MEDICAID RECIPIENT IS PLACED IN A NURSING FACILITY BUT THE SPOUSE REMAINS LIVING IN THE COMMUNITY. PLEASE PROVIDE COPIES OF THE FOLLOWING:

  • All Income Verification (Social Security Award Letter, Pension Stub, Etc.)
  • Spouse's ID & Cards
  • Electric Bills
  • Real Estate Tax Bills
  • Gas / Oil Bills
  • Mortgage Statements
  • Rent Receipts
  • Water / Sewer Bill
  • Home / Renter's Insurance

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