Bush LTCC Intake Form

It's time to get started.

... but don't worry, we are here to help you each step of the journey!

- The applicant is the person in need of Medicaid.
- The spouse is the spouse of the person in need of Medicaid.
NOTE: If spouse is deceased, no information is required for the spouse for the intake form.

Applicant's First Name

Applicant's Last Name

Spouse's First Name

Spouse's Last Name

Applicant's Address 1 (prior to entering nursing home.)

Applicant's Address 2

City

State

Zip/Postal Code

Spouse's Address 1 (if different from above)

Address 2

City

State

Zip/Postal Code

Nursing Home Name

Date Entered Nursing Home

Date Medicaid Needed

Applicant's Social Security Number

Spouse's Social Security Number

Applicant's Medicare Number

Spouse's Medicare Number

Applicant's D.O.B.

Spouse's D.O.B.

Does the applicant have Supplemental Insurance or Prescription Insurance?
Yes
No

Applicant's Supplemental Insurance

Does the spouse have Supplemental Insurance or Prescription Insurance?
Yes
No

Spouse's Supplemental Insurance

Cost of Supplemental Insurance and/or Prescription Premium for applicant.

Is there a Power of Attorney for the applicant?
Yes
No

Applicant's Gross Monthly Income

Spouse's Gross Monthly Income

Does the applicant and/or spouse own real property?
Yes
No

If property is owned, who owns the property?

If property is owned, what county and state is the property located in?

Does the applicant have life insurance?
Yes
No

If the applicant has life insurance, is it term life or whole life?
Term Life
Whole Life
Unsure

If the applicant has life insurance, what company is it written through?

Does the spouse have life insurance?
Yes
No

If the spouse has life insurance, is it term life or whole life?
Term Life
Whole Life
Unsure

If the spouse has life insurance, what company is it written through?

Do the applicant and/or spouse own any vehicles, boats, or trailers?
Yes
No

If the applicant and/or spouse own any vehicles, boats, or trailers, what is the Year/Make/Model?

Is there an irrevocable Prepaid Funeral Contract for the applicant or the spouse?
Yes
No

List all Bank Accounts for the applicant. (name of financial institution and account numbers)

List all Bank Accounts for the spouse. (name of financial institution and account numbers)

Does the applicant and/or spouse own any CD's?
Yes
No

If the applicant and/or spouse own any CD's, please list them here. (name of financial institution, account number, and balance)

Does the applicant and/or spouse have an annuity?
Yes
No

If the applicant and/or spouse own an annuity, please list it here. (name of financial institution, account number, and amount of monthly or annual payout)

Does the applicant and/or spouse have an investment account?
Yes
No

If the applicant and/or spouse own an investment account(s), please list them here. (name of financial institution, account number, and balance)

Does the applicant and/or spouse have an IRA?
Yes
No

If the applicant and/or spouse owns an IRA, please list it here. (name of financial institution, account number, and amount of last draw)

Has any money or property been given away by the applicant or spouse in the last 5 years?
Yes
No

Has anyone been added to the title of any asset in the last 5 years?
Yes
No

Representative's First Name

Representative's Last Name

Representative's Address 1

Address 2

City

State

Zip/Postal Code

Representative's Phone Number

Representative's Email

Submit

Bush LTCC Intake Form

It's time to get started.

... but don't worry, we are here to help you each step of the journey!

About

Quicklinks

Contact Info