Fill and Sign the Sample of Resignation Letter Form

HEALTH CARE APPLICATION FOR THE ELDERLY AND DISABLED AGENCY USE ONLY Case Number: Date Requested: Date Received: Interview Date: SFN 958 (9-2013) If you are not elderly or disabled and wish to apply for Health Care Coverage, complete the Application for Health Care Coverage (SFN 1909) or the Application for Assistance (SFN 405). Case Number: Instructions For Application For Health Care Coverage This application may be used to apply for Health Care Coverage, the Medicare Savings Programs, Aid to the Blind, or Basic Care. See the Guidebook for more information. What Do I Need to Do to Get Health Care Coverage? Follow these steps to apply for Health Care: Step 1: Check the assistance for which you are applying (Check ALL that apply). If you would like more information on these programs, see the Application for Assistance Guidebook. If you did not receive the Guidebook, contact your local social service office. Health Care Coverage – Medicaid coverage for the elderly and disabled. Aid to the Blind – Assists with treatment for people who are not eligible for Medicaid and are in danger of losing their vision or require restorative eye services. Medicare Savings Programs – Assists with Medicare Part B premium, coinsurance and deductibles. Basic Care Assistance – Helps pay for room and board and personal care in licensed basic care facilities. Step 2: Answer as many questions as you can. If you need help applying for assistance, you may have a friend, relative, or someone else help you apply. Your local county social service office can also help you apply for assistance. If you need additional space, attach a separate sheet of paper. Step 3: Sign and Return the completed application to your local county social service office. SFN 958 (9-2013) Page 2 of 8 To speed up the processing of your application, turn in verifications of the following items with your application. Your county social service office may be able to help you obtain these things if needed. Verification of Alien or Citizenship Status such as (original documents required): · Resident Alien Card (Form I-551) · Employment Authorization Card (Form I-688A) · Birth Certificate · · · · Temporary Resident Card (Form I-688) Arrival-Departure Record (Form I-94) U. S. Passport An official Tribal document for American Indians and Alaskan Natives You will be asked to provide information about the citizenship or immigration status for all persons for whom you want to receive assistance. If any of these persons do not want to give information about their citizenship or immigration status, they will not be eligible for benefits. Other household members may still get benefits if they are otherwise eligible. We will not share alien or citizenship information with the United States Citizenship and Immigration Service (USCIS). Verification of the value of current assets such as: Annuities Business Accounts Certificates of Deposit Checking/Savings/Credit Union Accounts · IRA/401K/KEOGH plans · · · · · · · · · Life Insurance Real Property (Land, Rental Property, etc.) Savings Bonds Stocks/Bonds/Mutual Funds Trusts Verification of expenses such as: · Court Ordered Payments (Child/Spousal Support, Medical Support) · Health Insurance Premiums Verification of income such as: · · · · · · · · Bonuses Child Support Commissions Lease Income Money from Friends, Relatives, or Others Pay (Pay Stubs or Employer Statement) Pension/Retirement Benefits Rental Income · Self-employment Income (most recent copy of Federal Income Tax Return) · Social Security Benefits · Spousal Support · SSI (Supplemental Security Income) · Unemployment Benefits · Veteran’s/Military Benefits · Workers Compensation Verification of Identity such as (original documents required): · Driver’s License · Picture identification card issued by employer · An official Tribal document for American Indians and Alaskan Natives To learn when you may get assistance, go to the General Information section of the Guidebook. If you have questions, contact your local county social service office. SFN 958 (9-2013) Page 3 of 8 Tell Us About You First Name Middle Initial Last Name Suffix Address Where You Live City State ZIP Code Mailing Address (if different) Home Telephone Number Work or Message Number Cell Phone Number Directions to Home (if rural) Would you like to receive text message notifications*? Yes No If yes, list name of cell phone provider: *By checking yes to this question, you agree to all message and data rates that apply. Yes Would you like to receive e-mail notifications*? No E-Mail Address *By checking yes to this question, you agree to all message and data rates that apply. Power of Attorney or Family Contact Person First Name Last Name Relationship Mailing Address Where You Want Notices Sent Home Telephone Number Work or Message Number Would you like to receive text message notifications*? Yes Cell Phone Number No If yes, list name of cell phone provider: *By checking yes to this question, you agree to all message and data rates that apply. Would you like to receive e-mail notifications*? Yes No E-Mail Address *By checking yes to this question, you agree to all message and data rates that apply. Tell Us About The People In Your Home Fill in the boxes below for yourself, spouse, if any, and anyone else in your home, including those temporarily out of the home for work, the military or medical reasons: If you need additional space, continue on a separate sheet of paper. Refer to the General Information section of the Application for Assistance Guidebook to determine what information is optional for you to provide. Household Members Relation Social Date of Marital Age Sex U. S. Hispanic Race (Enter Legal Name) Security Citizen or Latino To You Birth Status Middle Number (Yes or (Yes or Use Use First Initial Last No) No) Codes Codes Below Below Self Race Codes: AI - American Indian/Alaska Native Marital Status Codes: DI - Divorced MA - Married AP - Asian BL - Black/African American NM - Never Married SE - Separated HP - Native Hawaiian/Pacific Islander WH - White WI - Widowed If you do not want Health Care Coverage for all members of the household listed above, please list members you DO NOT want Health Care Coverage for: If you are applying for Health Care Coverage and are an enrolled member in a federally-recognized Indian tribe, you may be eligible for no enrollment fees or pemium payments under certain Health Care Coverage. Please list enrolled members and their tribal enrollment numbers: SFN 958 (9-2013) Page 4 of 8 Tell Us About Your Household I/We have lived in North Dakota since (month, day, and year): Do you intend to remain in North Dakota? Yes No List other names that have been used by household members (maiden name, prior married name or nickname): List household members temporarily out of the home: Why are they out of the home? Date Expected to Return: List household members who are disabled: If you have recently applied for disability and the decision by the Social Security Administration is still pending please provide proof of your pending status along with this application. List household members who have ever served in the military or who was a spouse of someone that served: Have household members received medical assistance in another state? If Yes, When? Yes No Which City, County, and State: Does anyone in your household require nursing care services? Yes No If yes, when did/will they start receiving nursing care services? If receiving nursing care services in a facility, which facility? Tell Us About Your Medical Bills Medicaid may be able to help pay medical bills, including prescription costs, for up to three months prior to the month of your application. Would you like help paying any of these bills? Yes No If yes, list each month: Medicaid can allow unpaid medical bills older than three months to reduce your out-of-pocket costs. Do household members have unpaid medical bills older than three months? Yes No If yes, explain: Tell Us About Your Household Assets Assets Check yes by the assets owned, jointly owned, or being purchased by household members. Check no, if none. Yes Yes Yes Yes No No No No Annuities Assets Owned with Another Person Burial Plots Burial Space Items (Casket, Vault, Marker, etc.) Yes Yes Yes Yes Yes No No No No No Yes Yes Yes Yes No No No No Business Accounts Business Inventory/Equipment Cash on Hand Certificates of Deposit Debit Card Account (other than checking/savings account) Checking/Credit Union Accounts Farm Equipment, Livestock, Stored Grain Home/Mobile Home (Not Owner Occupied) Home/Mobile Home (Owner Occupied) Yes Yes No Income Producing Tools/Equipment No Life Estate/Life Lease Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No Mineral Rights (Oil, Gas, Gravel, Coal, etc.) Notes or Contract for Deed Prepaid Funeral Plans Real Property (Land, Rental Property, Buildings, etc.) Retirement Funds (IRA/KEOGH/401K) Safety Deposit Box Savings Bonds Savings/Credit Union Accounts Stocks/Bonds/Mutual Funds Trusts Other, specify: Household Assets continued on next page SFN 958 (9-2013) Page 5 of 8 Tell Us About Your Household Assets (continued) Tell Us About Your Household Assets For all items checked yes, fill in the boxes below: Type of Asset Location/Description Are any assets subject to a "Transfer at Death"? Yes Total Value Amount Owed Owners No If yes, describe the property and approximate value. List household members who have made arrangements for funeral expenses or gave money, property, or insurance to someone else to pay for funeral expenses: Explain: Do you expect changes in assets next month? Yes No If yes, explain: Transfer of Assets Have household members sold, given away or transferred anything of value within the past 5 years? Yes If yes, list the items: No Date Life Insurance Does any household member have life insurance? Name of Insured Person Name and Address of Company Yes No If yes, fill in the boxes below: Policy Number Face Value Cash Surrender Value Owners Continue on next page SFN 958 (9-2013) Page 6 of 8 Vehicles List vehicles (car, truck, motor home, snowmobile, motorcycle, 3 wheeler/4 wheeler, boat or other watercraft, camper, trailer, etc.) owned, jointly owned or being purchased for all household members, even if the vehicle is not running or not in your possession. Include vehicles licensed through North Dakota, tribal motor vehicle or another state. Make/Model Year Value Amount Owed Owners Tell Us About the Income/Money Your Household Receives Have household members sold, given away or transferred any income or stream of income within the past 5 years? (Example: annuity payments, VA improved pension) Yes No If yes, explain: Self-Employment Are any household members self-employed? Yes No If yes, complete the following: Name of Household Member: Name and Type of Business: Date Business Started: Employment Are any household members employed? Yes No If Yes, list information about pay from employment such as wages, commissions, bonuses, and incentives for all household members. If employment stopped last month or this month, also list income received this month here. Household Member Employer Hours Worked Per Week Hourly Pay How Often Paid Codes: M - Monthly 2X - Twice a Month W - Weekly EX - Every Two Weeks Day Paid Codes: M - Monday T - Tuesday W - Wednesday TH - Thursday F - Friday Have any household members received commissions, bonuses or incentives other than those included above within the last year? Name of Household Member: This Month's Next Month's Pay Before Pay Before Amount Taxes (Gross) Taxes (Gross) of Tips Date of Next Check How Day or Often Dates Paid Paid Use Codes Below Other, specify: S - Saturday Yes No Date Received: SU - Sunday If yes, complete the following: Amount Received: Unearned Income or Other Money Received The following is a list of different kinds of unearned income. Check yes for each unearned income or other money received by household members. Check no, if not received. Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No BIA/Tribal General Assistance Bingo/Gambling Winnings Child Support or Spousal Support Contract Sale or Rental Income Income from Tribes Income from Roomer/Boarder Insurance/Lawsuit Settlement Interest/Dividend Income Money from Friends, Relatives or Others Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Yes No Other, specify: Oil/Mineral Rights/Royalties Pension/Retirement Benefits Railroad Retirement Benefits Social Security Benefits Supplemental Security Income (SSI) TANF-Temporary Assistance for Needy Families Unemployment Benefits Veteran's/Military Benefits Workers' Compensation SFN 958 (9-2013) Page 7 of 8 For all items checked yes, fill in the information below: Type of Unearned Income or Household Member Other Money Received How Often Received Have household members applied for benefits not yet received (Social Security, SSI, Worker's Compensation, Unemployment Compensation, Veterans/Military Benefits?) Yes Amount Next Month Amount This Month No If yes, explain: Tell Us About Court Ordered Expenses Is any household member court ordered to pay child support, spousal support, other support or health insurance? If yes, who? No Who are the payments for? Amount Court Ordered: Yes Amount Paid: Tell Us About Your Health Insurance Coverage List household members who have health insurance: Persons Covered List all that apply A - Hospital B - Doctor C - Major Medical/Lab/X-Ray D - Dental Policy Holder Name and Address E - Vision F - Nursing Home G - Cancer H - Champus/Tricare Health Insurance Name and Address Effective Date Policy Number I - HMO Insurance J - Court Ordered K - Medicare Part A L - Medicare Part B M - Medicare Supplement/Advantage Group Number Monthly Premium Type of Coverage Use Codes Below N -Prescription Drug Insurance P - Workers Compensation or Accident V - Veterans Administration W - Medicare Part D Does anyone outside the household pay the premium? Yes No If yes, who? Do household members expect changes in health insurance coverage? Yes No If yes, explain: SFN 958 (9-2013) Page 8 of 8 Tell Us if Someone Else May Help With Your Medical Costs Does anyone help pay your medical costs? Yes No If yes, explain: Do household members have medical problems due to an accident? Yes No If yes, complete below: Type of Accident: Date of Accident: Do household members have a pending legal action from which they may receive money or medical benefits (including inheritance?) Yes No Basic Care Applicants Only If you are requesting coverage for the month you enter a Basic Care Facility, list the amount of rent and utilities you will pay this month. This includes rent, mortgage, lot rent, electricity, heating, water, garbage, property taxes, telephone, etc. These expenses may be deducted from your first month's room rate at the basic care facility. Provide hard copy verification for each expense listed. Type of Expense Total Amount Paid Type of Expense Total Amount Paid Read The Following Information I have received, reviewed and understand my rights and responsibilities as explained in the Application for Assistance Guidebook. I declare under penalty of law, the information on this application is correct. This includes information about identity, citizenship and alien status of the household members applying for assistance. I understand that alien status information and other information will be verified when discrepancies are found. Verification received may affect eligibility and level of benefits. I understand the information I provide on or with this application is subject to verification by federal, state and local officials to determine if the information is correct. If any of the information is incorrect, assistance may be denied and I may be subject to criminal prosecution for knowingly providing incorrect information. I agree to report to the county social service office any changes in income, assets, or living arrangements as required. I understand I will not receive a deduction for any allowable expenses I do not report and verify. Authorization To Release Information I/We authorize any person having custody or knowledge of the information relating to me or other household members to disclose any requested information, including confidential information other than protected health information, to any authorized agent of the North Dakota Department of Human Services. This authorization will remain valid until canceled in writing or until coverage ends. I/We authorize Child Support to release any records of child support payments that I/we have made or received. A copy of this authorization is as valid as the original. Sign And Date The Application Here Signature of Applicant: Date: Other Signature (Spouse, Guardian or Other Adult): Date: