GA DHR 700 2011-2025 free printable template

PERSONAL INFORMATION You may have someone help you complete this application. Applicant s Name Last First Middle Initial Mailing Address If you wish to name a person to act on your behalf complete the information below Name Last First Middle Initial Street Address City State Zip Do you own/are you purchasing home Phone County Nursing Facility if applicable Y N Relationship to Individual COMPLETE THIS INFORMATION FOR YOU AND YOUR SPOUSE. Name Self Birthdate Sex Race U.S. Citizen Yes or No Social...Security Number Marital Status Maiden/other name s Name Spouse Are you applying for your spouse too Are you blind or disabled Yes Yes No - Is your spouse blind or disabled Yes LIVING ARRANGEMENT Check the box es that best describes your current situation. Living In Own Home Nursing Facility Date Admitted DHR 700 R. 05/11 Another s Home Hospice Hospital Katie Beckett Community Care Assisted Other/ Renting HEALTH INSURANCE Do you have Medicare Are you enrolled in a Medicare HMO or Medicare Drug...program Does your spouse have Medicare Type of Coverage Effective Date Part A Part B Part D RX doctor Medicare Number Have you ever received SSI If so when did it end Has your spouse Do you have other health insurance If you answered yes to either of these questions please complete the following information Health Insurance Effective Policy Company Name Hospital Medicare Address and Telephone Supplement Drugs Major Medical Self Spouse Attach copies front and back of Medicare and insurance cards...if applicable. Georgia Application for Medicaid Medicare Savings for Qualified Beneficiaries QMB - payment of premiums coinsurance and deductibles SLMB - payment of Part B premium and QI-1 - payment of Part B premium INSTRUCTIONS 1. Read the application carefully answer each question accurately. Attach additional pages if needed* 2. Sign and mail application to County DFCS Mail or deliver application to the DFCS office in your county of residence ATTN 3. A telephone interview may be required for...these programs. Be sure to enter phone below. 4. The DFCS Medicaid Specialist will review this application* If it appears that you may be eligible for full Medicaid coverage the Medicaid Specialist will contact you for more information and verifications. REAL PROPERTY Do you own all or part of any real estate in which you do not live Yes No If yes please complete the following for each piece of real estate. Do not list the house or mobile home in which you live. Address Value Amount Owed Do...you or your spouse own a car truck boat camper utility trailer recreational vehicle etc* Yes No If yes please complete the following information about each vehicle. Attach additional pages if needed* Type Year Make Model RESOURCES Check all resources assets owned by you your spouse or jointly owned with someone else. Include any accounts or properties on which your name s appear. Attach additional pages if necessary. Checking account Funeral plans/ prepaid burial item Yes No Savings account...Burial plots or contracts Stocks and bonds Government bonds Trust funds Other IRA CD promissory note etc* Yes No Have you or your spouse given away any assets for less than its value Type of Resource Account/ Policy Name of Bank Insurance Company Etc* Policy Owner Insurance Company Policy Number Face Cash Value INCOME AND EARNINGS List all types of earnings and income that you and your spouse receives.