Application for Mississippi Medicaid Aged, Blind and

Disabled Medicaid Programs

• This application is used to apply for Medicaid due to age, blindness or disability. An individual or couple may use this form to apply. This form & other program information is available on the MS Division of Medicaid’s website www.medicaid.ms.gov • Please read each question carefully before answering. The answers given will determine whether or not

the person(s) applying will be eligible for Medicaid. A friend or relative may help the applicant complete this form. A Medicaid worker is also available if any help is needed.

• Contact your worker if you want to register to vote or update your voter registration information.

What is the language most spoken in your home . If not English and you need assistance, contact your Regional Office or call 1-800-421-2408. An interpreter service will be provided free of charge. If any person(s) applying for Medicaid using this form is blind or hearing impaired, enter the name(s) in this space so that any special needs can be evaluated: __________________________________________________________________________________________________ Are there any other special needs? __________________________________________________________________________________________________■ WHEN THIS FORM IS COMPLETED AND SIGNED, YOU CAN EITHER MAIL, FAX OR BRING IT TO YOUR MEDICAID REGIONAL OFFICE AT THE FOLLOWING ADDRESS: For Regional Office Use Only: LTC Facility ______________________________________ HCBS Waiver Type _____________________________ Healthier MS Waiver Medicare Cost Sharing DCLH Working Disabled SSI Retro Deemed SSI Other ____________________________________ Worker: ________________________________________ Date & Place of Interview _______________________________ Case Name ______________________________________ Case Number ________________________________________ Spouse Case Name ________________________________Case Number ________________________________________ Rights & Responsibilities explained at time of interview? Yes No Programmatic Pamphlet(s) provided? Yes No

DOM-300 Revised 08/01/2015

http://www.medicaid.ms.gov/

1. USE OF MEDICAID PLANNER – Has anyone paid (or is paying) for the services of a Medicaid Planner in completing this application? Yes No If yes, provide the following information: Name of Medicaid Planner ______________________________________________________________

Contact Information for Planner _________________________________________________________

Name Applicant(s) Using Medicaid Planner Service__________________________________________

2. APPLICANT INFORMATION – Enter all information about the 1st applicant:

Applicant’s Full Name: ______________________________________________________________________ (First) (Middle) (Maiden) (Last) Social Security Number: _______ - _____ - _________ Date of Birth: (Mo) _____ (Day) _____ (Year) _________

Marital Status: Single Married Separated Widowed Divorced Gender: Male Female

Race: (optional) check all that apply: White Black American Indian or Alaska Native Chinese Asian Indian Filipino Japanese Korean Vietnamese Other Asian Native Hawaiian Samoan

Guamanian or Chamorro Other Pacific Islander Other ____________________________________________ If Hispanic/Latino, check all that apply (optional) Mexican Mexican-American Chicano/a Puerto Rican Cuban Other _______________________________________________________________________________

This applicant is applying on the basis of: age (65 or over) blindness disability (describe the disability): _____________________________________________________________________________

Applicant lives: in own home rental home or apt. with someone in their home – please list whose home __________________ nursing facility other ________________________________________

Telephone (Home) ____________________ (Cell) ______________________ (Other) _______________

Does applicant plan to enter a nursing facility? Yes No If yes, when? _________________________

Enter name & location of nursing facility ________________________________________________________________

If in a nursing facility, did applicant enter directly from a hospital home other ________________

Home Address: ________________________________________________________ Apt. or Lot # ___________

City: ________________________________County: _________________State: _______ Zip: ________

Who lives at this address now? _________________________________________________________________

________________________________________________________________________________________________________

Mailing Address (if different) _________________________________________________________________________

City: _________________________________County: ________________State: ______Zip: __________

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Name of Applicant(s) ________________________________SSN(s)________________________________

Is applicant a U.S. citizen? Yes No If no, when did applicant enter the U.S.? _________________ If not a U.S. citizen, is applicant in a satisfactory immigration status? Yes No (Not required for immigrants seeking Emergency Medicaid services.) A list of satisfactory immigration statuses for Medicaid purposes is available from a Medicaid Regional Office.

Previous Marriages: Has applicant ever been widowed or divorced? Yes No If yes, enter information for all previous marriages:

Former Spouse’s Name (First) (Middle) (Maiden) (Last)

How Long Married

How Marriage Ended (Death or Divorce)

Does applicant have Medicare Part A? Yes No Medicare Part B? Yes No If yes, enter

the Health Insurance Claim # as shown on the Medicare card: _____________________________________

Does applicant have other health insurance? Yes No If yes, enter the following information:

_______________________________________________________________________________________ Insurance Company Group or Policy # Begin Date End Date (if ending) Does applicant receive Medicaid from another state? Yes No If yes, complete the following: Name of State ___________________ Date Medicaid will close __________________________________ Legal Representative: Does this applicant have a court appointed guardian or conservator? Yes No Has this applicant appointed Power of Attorney to anyone? Yes No If yes, give the name, address & phone # of the person legally appointed to act for this applicant: Verification of guardianship, conservatorship or power of attorney will be required. Name/Address __________________________________________________________________________

Phone #s _________________________________Relationship to Applicant _________________________

Authorized Representative: If there is no legal representative, would this applicant like to name a person to act as their representative? Yes No. A representative acts in the applicant’s behalf on matters relating to this application, including providing needed information. Enter the name, address & phone number of the person representing this applicant: Name/Address __________________________________________________________________________

Phone #s _________________________________Relationship to Applicant _________________________

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3. SPOUSE OR PARENT INFORMATION - Provide the following information for the spouse of the applicant or information on the parent applying for a minor disabled child. The spouse of Applicant #1 may also apply by completing this entire section. Full Name of Spouse or Parent ________________________________________________________________________ Social Security Number*: ______ - ____ - ________ Date of Birth: (Mo) _____ (Day) _____ (Year) __________ (*not required unless spouse is applying) Marital Status: Single Married Separated Widowed Divorced Gender: Male Female

Race: (optional) check all that apply: White Black American Indian or Alaska Native Chinese Asian Indian Filipino Japanese Korean Vietnamese Other Asian Native Hawaiian Samoan Guamanian or Chamorro Other Pacific Islander Other ____________________________________________ If Hispanic/Latino, check all that apply (optional) Mexican Mexican-American Chicano/a Puerto Rican Cuban Other _______________________________________________________________________________

Telephone (Home) ____________________(Cell) ______________________(Other) _________________

Home Address (if different from Applicant #1) ________________________________Apt .or Lot# _____ City: _________________________________County: __________________State: ______Zip: ________

Mailing Address (if different from above) ___________________________________________________

City: ________________________________ County: __________________State: _____ Zip: ________

Who lives at this address now?

_______________________________________________________________________________________________________ Is spouse applying for Medicaid on this application? Yes No If yes, answer all of the following questions as Applicant #2. If spouse is not applying, skip to Question #4. If parent is applying for a minor disabled child, skip to Question #4. Applicant #2 is applying on the basis of: age (65 or over) blindness disability (describe the disability): _____________________________________________________________________________

Applicant #2 lives: in own home rental home or apt. with someone in their home – please list whose home __________________ nursing facility other __________________________________

Does Applicant #2 plan to enter a nursing facility? Yes No If yes, when? _____________________

Enter name & location of nursing facility _____________________________________________________

If in a nursing facility, did Applicant #2 enter directly from a hospital home other _____________

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Name of Applicant(s) ________________________________SSN(s)________________________________

Is Applicant #2 a U.S. citizen? Yes No If no, when did spouse enter the U.S.? ______________ If not a U.S. citizen, is Applicant #2 in a satisfactory immigration status? Yes No (Not required for immigrants seeking Emergency Medicaid services.) A list of satisfactory immigration statuses for Medicaid purposes is available from a Medicaid Regional Office.)

Previous Marriages: Has Applicant #2 ever been widowed or divorced? Yes No If yes, enter information for all previous marriages:

Former Spouse’s Name (First) (Middle) (Maiden) (Last)

How Long Married

How Marriage Ended (Death or Divorce)

Does Applicant #2 have Medicare Part A? Yes No Medicare Part B? Yes No If yes,

enter the Health Insurance Claim # as shown on the Medicare card: ___________________________________

Does Applicant #2 have other health insurance? Yes No If yes, enter the following information:

______________________________________________________________________________________________________ Insurance Company Group or Policy # Begin Date End Date (if ending) Does Applicant #2 receive Medicaid from another state? Yes No If yes, complete the following: Name of State ___________________ Date Medicaid will close __________________________________ Legal Representative: Does Applicant #2 have a court appointed guardian or conservator? Yes No Has Applicant #2 appointed Power of Attorney to anyone? Yes No If yes, give the name, address & phone # of the person legally appointed to act for Applicant #2: Verification of guardianship, conservatorship or power of attorney will be required. Name/Address __________________________________________________________________________

Phone #s _________________________________Relationship to Applicant _________________________ Authorized Representative: If there is no legal representative, would Applicant #2 like to name a person to act as their representative? Yes No. A representative acts in the applicant’s behalf on matters relating to this application, including providing needed information. Enter the name, address & phone number of the person representing Applicant #2: Name/Address __________________________________________________________________________

Phone #s _________________________________Relationship to Applicant _________________________

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4. RETROACTIVE MEDICAID – Medicaid may be able to cover Applicant #1 and Applicant #2 (if applicable) for the 3 months prior to the date of this Medicaid application or the date an application was filed for SSI. Each applicant must be determined eligible for each requested month and have received services covered by Medicaid during the retroactive period. The month of application is the month Medicaid receives this signed form.

Does Applicant #1 want to apply for retroactive Medicaid? Yes No If yes, enter month(s) needed ______________________________________________________________________________________________

Does Applicant #2 want to apply for retroactive Medicaid? Yes No If yes, enter month(s) needed ______________________________________________________________________________________________

5. VETERAN STATUS

Is Applicant #1 a veteran? Yes No Has Applicant #1 ever been married to a veteran (living or not)? Yes No Is Applicant #2 a veteran? Yes No Has Applicant #2 ever been married to a veteran (living or not)? Yes No Is Applicant a dependent of a veteran? Yes No If yes to any of these questions, complete the following: Name of Veteran _______________________________________Relationship to Applicant ____________ Dates of Service __________________________________Branch of Service _______________________ Has Applicant #1 ever applied for VA benefits? Yes No Has Applicant #2 ever applied for VA benefits? Yes No If yes for Applicant #1 or #2, please provide proof of the VA decision to grant or deny benefits.

6. INCOME AND WORK HISTORY – The Division of Medicaid is required to verify all income received and resources owned by each applicant, each applicant’s spouse (applying or not applying) and the parent(s) of a minor disabled child. If this application is for a minor disabled child, please check one of the following: I will provide parental financial information so that my child can be considered under any and all categories of eligibility for Medicaid and/or CHIP. Enter information for parent(s) and child applicant below.

I elect to have my child’s eligibility considered only under the Disabled Child Living At-Home (DCLH) category and will not provide any parental income or resource information to use for evaluation under any other category of eligibility. The DCLH category requires the income/resources of the disabled child to be verified. Enter income and resource information for the child applicant below.

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Name of Applicant(s) ________________________________SSN(s)________________________________

Does applicant, spouse (applying or not) or parent(s) of a minor disabled child work? Yes No If yes, name person(s) working: _________________________________________________________________ Name of Employer(s): _________________________________________________________________________ Total wages (before deductions) $ ___________________How often paid? ____________________________ If paid weekly or biweekly, what is day of week paid? ________________ Wages must be verified for the last 3 months. Copies of check stubs or wage printouts are examples of verification that can be provided. Is applicant, spouse (applying or not) or parent(s) of a minor child currently self-employed or self-employed during the last 12 months? Yes No If yes, name person(s) currently or previously self-employed:_____________________________________________________________________________ Type of business _____________________________________End Date (if not active) _______________ Self-employment must be verified. A copy of the last federal tax return verifying net earnings is required. If a tax return is not available, another form of verification will be required.

If not currently employed, what is the last date of employment (for the applicant, spouse or parent(s) of a minor disabled child)? Provide employer(s) name and ending date of employment:

_____________________________________________________________________________________________

Did applicant, spouse or parent(s) file a federal tax return last year? Yes No

Are there children under the age of 18 in the home that have income? Yes No If so, name the child and the source/amount of income ___________________________________________________________________________________ Income of a child (not applying for Medicaid) is used to determine how much of a non-applying spouse’s or parent’s income is counted.

Complete the next 2 questions only if applicant #1 or #2 is in a nursing facility:

• If applicant has a spouse living at-home, does applicant wish to make his or her income available to the community spouse? Yes No

• Does applicant in the nursing facility receive sheltered workshop earnings or any income from work therapy? Yes No If yes, what are the monthly earnings? $___________________________

All other income received by the applicant, spouse (applying or not) or parent(s) of a minor disabled child must be verified for eligibility purposes. If an electronic verification source is available to us, we will verify the income for you. Otherwise, verification needs to come from the source of the payment. You will be asked to provide a check stub or other official document. Enter the gross amount (before any deductions) of income received from any source in the space below:

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Source of Income How Often Received

Applicant #1 Applicant #2 or Spouse

Parent of Minor Disabled Child

Parent of Minor Disabled Child

Social Security $ $ $ $ SSI $ $ $ $ Railroad Retirement $ $ $ $ VA Pension $ $ $ $ VA Compensation $ $ $ $ Other VA Benefits $ $ $ $ Military Retirement $ $ $ $ State Retirement $ $ $ $ Federal Civil Service $ $ $ $ Municipal Retirement

$ $ $ $

Private Pension $ $ $ $ Unemployment Compensation

$ $ $ $

Rental Income $ $ $ $ Workers’ Comp. $ $ $ $ IRA Income $ $ $ $ Annuity Income $ $ $ $ Interest Income $ $ $ $ Trust Income $ $ $ $ Dividends $ $ $ $ Promissory Note Income

$ $ $ $

Oil, Gas or Mineral or Timber Leases

$ $ $ $

Government Payments on Land

$ $ $ $

Royalties $ $ $ $ Child Support $ $ $ $ Alimony $ $ $ $ Cash Contributions $ $ $ $ Public Assistance (TANF or other)

$ $ $ $

Other (specify)

$ $ $ $

Other (specify)

$ $ $ $

If applying for long term care in a nursing facility or Home & Community Based waiver services, has the applicant or spouse given away any income or the rights to income or the right to receive income within 5 years of this application? Yes No If yes, verification will be required for all transfers of income.

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Name of Applicant(s) ________________________________SSN(s)________________________________

7. RESOURCES –Report real or personal property owned or being purchased in part or in whole by the applicant, spouse (applying or not) or parent(s) of a minor disabled child. Not all resources count for eligibility purposes but you must tell us about all resources. Enter requested information below:

Home Property: Yes No If yes, enter State/County of Home __________________________________ Address/City __________________________________________________________________________________

If ownership is shared, who else is on the deed ____________________________________________________

Does anyone live in the home? Yes No If yes, who? __________________________________________

Is the home being rented or does it produce income? Yes No Is yes, explain _____________________

______________________________________ Amount of rental income $ ________________________________

Does applicant owe money on the property? Yes No If yes, what is owed? $___________________

Does applicant have a reverse mortgage? Yes No If yes, what are payments? $ __________________ The most recent deed & tax receipt may be required to verify home property.

Other Real Property Yes No If yes, number of other properties: _____________________________ If yes, list each property below: Copies of deeds and tax receipts will be required to verify other real property.

Location of Each Property (City, County, State)

Type of Ownership Name on Deed

Who Lives on Property?

Income Produced by Property

$

$

$

$

$

Does applicant own a mobile home? Yes No If yes, who owns the land where the mobile home is located? _____________________________________________________________________________________________

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Has applicant or spouse sold or given away home or non-home property within 5 years of this application? Yes No If yes, give date(s) and describe the property that was sold or transferred: _____________________________________________________________________________________________ Copies of deeds showing current ownership or ownership at the time property was sold or transferred will be needed on all property owned or owned within the last 5 years in order to determine eligibility for long term care and Home and Community Based Services (HCBS) applicant(s). Cash on Hand – Does applicant, spouse or parent(s) keep cash on hand (greater than $200 spending money)? Yes No If yes, how much? $ ____________________________________________ Funds Held in a Bank or Credit Union – Check all of the following types of accounts individually or jointly owned or used by the applicant, spouse or parent(s) to hold funds belonging to the applicant, spouse or parent. Verification of balances will be needed from the bank/credit union. Checking Account(s) Direct Deposit Debit Card Account Savings Account(s) CD(s) Conservatorship Account Funds Held in a Bank Account Owned by Another Fund Raiser Account IRA Annuity Safety Deposit Box College Savings Fund Enter information for each account below:

Name of Bank Type of Account Account Number Name(s) on Account Current Balance $

$

$

$

$

If applicant is in a nursing facility, is there a patient account at the facility? Yes No Have any accounts been closed, names changed or funds transferred from any account(s) in the last 5 years? Yes No If yes, explain: ______________________________________________________________________________________ Verification of changes in accounts may be required for long term care and HCBS waiver applicant(s). Retirement Funds – Does applicant, spouse or parent(s) have retirement funds on deposit from a pension plan, IRA, annuity, or other type of fund? Yes No Has periodic payment from this fund or funds been requested? Yes No Is the owner of these fund(s) still employed & working? Yes No

Owner of Retirement Fund(s) _________________________________Verification of funds will be required.

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Name of Applicant(s) ________________________________SSN(s)________________________________

Annuities – Does applicant, spouse or parent(s) own, individually or jointly, an annuity? Yes No

If yes, name owner(s) ____________________________________________________________________

Initial investment $ ______________ Date purchased ___________ Name annuitant __________________

Does annuity produce fixed monthly payments? Yes No Are payments based on entire investment? Yes No Each annuity must be verified by providing the annuity contract. Other information may also be required. Trust Funds – Is the applicant, spouse or parent(s) the beneficiary of a trust? Yes No If yes, enter

Trustee’s name/address/telephone __________________________________________________________

Has a trust been set up using assets belonging to the applicant, spouse or parent(s)? Yes No A copy of any/all trusts created by the applicant, spouse or parent(s) in full or in part must be provided. Promissory Notes, Loans or Property Agreements – Does applicant, spouse or parent(s) own an

agreement for repayment of money loaned or property sold? Yes No If yes, enter the following:

Balance of Loan $____________ Income Received $____________ How Often? ______________

A copy of the note or agreement will be required in order to determine eligibility for the applicant(s). Stocks, Bonds or Similar Investments– Check all of the following types of investments owned by the applicant, spouse or parent(s): Stocks Mutual Fund Shares Corporate Bonds Municipal Bonds Government Bonds/U.S. Securities U.S. Savings Bonds Foreign Investments Other ____________________________. Enter information for each investment owned:

Type of Investment Owner(s) Current Value $

$

All investments owned must be verified by an official document confirming value.

Automobiles (Cars, Trucks, Motorcycles, Boats) – List any vehicle used for transportation owned by the applicant, spouse, parent(s)

Type of Vehicle Owner(s) Model/Year Amount Owed

Verification of ownership of vehicles may be required.

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Personal Property – Includes recreational vehicles, campers, and boats used for recreation only, antiques or other collectables of substantial value. Does applicant, spouse or parent(s) own any personal property of this type? Yes No If yes, what is owned? _________________________________________________________________________________________ Describe and give value: ___________________________________________________________________ Verification may be required to confirm the value. Life Insurance – Does applicant, spouse or parent(s) own life insurance? Yes No If yes, specify:

Owner Insured Face Value Insurance Co. Whole Life Term

Whole Life Term

Whole Life Term

Whole Life Term

A copy of the face value page is needed for verification.

Burial Funds – Does applicant, spouse or parent(s) have funds set aside for burial? Yes No If yes,

How are funds set up? Burial Insurance Pre-Need Contract With Funeral Home Other (specify)

______________________________________________________Value of fund(s) $_______________ Verification of the value of the funds and whether funds are accessible may be required. Burial Spaces - Does applicant, spouse or parent(s) own burial plots or spaces? Yes No If yes,

Number of gravesites owned _______Location of Cemetery ___________________________________

Are all gravesites used / intended for use by family members of applicant? Yes No

Other – Are there any other resources owned or being bought by the applicant, spouse or parent(s) that are not shown above in the Resource section? Yes No If yes, specify type & value of resource:

__________________________________________________________________________________________

Resource Activity in the Last 5 Years – Has the applicant or spouse sold or given away any resources within 5 years of this application that have not already been disclosed on this application?

Yes No If yes, specify: __________________________________________________________________

A 5-year look back period may be imposed for nursing home and Home &Community Based waiver applicant(s). Verification of any/all transfers identified within the last 5 years will be required.

8. STATEMENT OF RESIDENCY – Does Applicant #1 plan to remain in Mississippi? Yes No Does Applicant #2 plan to remain in Mississippi? Yes No

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Name of Applicant(s) ________________________________SSN(s)________________________________

9. ESTATE RECOVERY – The Estate Recovery provision applies to Medicaid recipients age 55 or older and in a nursing facility or enrolled in a Home & Community Based Waiver program at the time of death. If this applies to either Applicant #1 or Applicant #2 or both, please read the following:

I understand that upon my death the Division of Medicaid has the legal right to seek recovery from my

estate for services paid by Medicaid in the absence of a legal surviving spouse or a legal surviving dependent. Consideration will be made for hardship cases. An estate consists of real and personal property. I understand that homestead property is in many cases protected from the claims of creditors and exempt from judicial sale and that, by signing this contract, I voluntarily give up my right to this protection for this property with respect to claims based upon this contract.

10. PRIVACY ACT AND USE OF SOCIAL SECURITY NUMBERS – The MS Division of Medicaid is

authorized to determine eligibility for Medicaid and is protected by law from disclosure to unauthorized persons. It is possible that this form may be used to determine another person’s right to Medicaid benefits. Pursuant to the authority found in federal law at 42 U.S.C. 1320b-7(a) and federal regulations at 42 CFR 435.910, you are required to disclose the Social Security Number (SSN) for each person applying for Medicaid. This is a mandatory requirement in order to be eligible for Medicaid benefits, unless an applicant is a non-qualified alien seeking emergency Medicaid services. If you cannot recall the SSN for each applicant or if the applicant does not have a SSN, the agency can assist you in applying for a SSN for each applicant. If the applicant has a well-established religious objection for not providing his or her SSN, he or she should state the basis for such objection and the agency will review this request. The SSN will be used to verify information such as assets, income and insurance coverage and to help maintain files regarding eligibility pursuant to the authority described in federal regulations 42 CFR 435.940 through 42 CFR 435.960. Consistent with Federal Law, Section 1940 of the Social Security Act (42 USC 1396w), which mandates asset verification services by all state Medicaid agencies, and Mississippi House Bill 1391, the SSN will be used for electronic verification of disclosed and undisclosed assets. The SSN may also be used to match with records within the State Medicaid agency and in other state, federal, and/or local agencies, such as the Social Security Administration, Internal Revenue Services, and Employment Security as well as banks and other financial institutions.

11. DISCLOSURE OF FINANCIAL INFORMATION - By signing this application, you are certifying

that to your knowledge all financial information provided is true and correct. In addition, you are authorizing any financial institution to disclose information concerning financial accounts held by that institution to the MS Division of Medicaid or its designated agent or contractor for the purpose of identifying and verifying your assets at application and redetermination for Medicaid eligibility. This includes the amount of deposits and any other information described in or solicited from the financial institution, including an account history request. This authorization is effective until Medicaid eligibility is denied or Medicaid eligibility ends or you revoke this authorization, whichever occurs first. You may revoke this authorization at any time by notifying the MS Division of Medicaid in writing of your desire to revoke this authorization; however, such revocation would prevent eligibility from being determined or redetermined. This authorization of information disclosure does not alter or waive your right under the Right to Financial Privacy Act, 12 U.S.C. 3401 et seq., except to the extent that certain such rights may be modified by the asset verification provisions of Section 1940 of the Social Security Act, 42 USC 1396w.

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12. RIGHTS AND RESPONSIBILITIES OF APPLICANTS

• I understand that if this application shows that I may be eligible for payments or benefits from other sources, I am required to apply for them.

• I understand that as a condition of receiving Medicaid, the MS Division of Medicaid may become a remainder beneficiary on any annuity that I or my spouse purchased or on which we performed certain transactions on or after February 8, 2006.

• I understand that if I am awarded Medicaid in a nursing facility that part or all of my income must be applied toward the cost of my care in the facility, as directed by the MS Division of Medicaid.

• I understand that my case is subject to review by state or federal auditors or for quality control purposes and I must cooperate with reviewers. No additional permission is needed to get verification or other information.

• I assign all insurance and medical support benefits to Medicaid if I am approved for Medicaid. If Medicaid pays my bills, then my insurance or other benefits (such as lawsuit settlements) must be used to reimburse Medicaid. By accepting Medicaid, I agree to give up my rights to any third party payments to the MS Division of Medicaid. I agree to help and cooperate with the MS Division of Medicaid in identifying and collecting this money, or I may lose my Medicaid.

• I agree to notify the MS Division of Medicaid within ten (10) days if there is a change in my address, living arrangement, family size, income or resources. I also agree to notify the MS Division of Medicaid if I return to work, am discharged from a nursing facility or hospital or move from one facility to another. I will report any improvement in my medical condition if I am receiving Medicaid due to disability or blindness.

• In-person interviews are required for new applications and may be required for annual reviews. • An annual review is required for all Medicaid recipients. Adults may be reviewed more than once

per year depending on the types of changes reported during the year. • Information you share is confidential. Your medical information can only be released if needed to

administer the Medicaid program. If you receive care or treatment under Medicaid, you authorize the health care provider to release to Medicaid your medical records and information relating to your diagnosis, examination and treatment.

• You may ask for a hearing if you are not satisfied with any action taken by the MS Division of Medicaid in connection with this application.

• Your application will be considered without regard to race, color, age, handicap, religion, national origin, political belief or limited English proficiency. The MS Division of Medicaid complies with all state and federal policies which prohibit discrimination as defined through The Americans with Disabilities Act of 1990, the Rehabilitation Act of 1973 and the Civil Rights Act of 1964.

• Adults eligible for Medicaid should get a yearly health screening (health exam) from your doctor or clinic. This exam will not count against your annual doctor visit limit under Medicaid. Children under age 21 who are eligible for Medicaid are eligible for a free health care prevention program that provides a way for children to get medical exams, check-ups, follow up treatment and special care to make sure they maintain good health.

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Name of Applicant(s) ________________________________SSN(s)________________________________

13. RELEASE OF INFORMATION – I hereby authorize and give my consent for the MS Division of Medicaid to obtain information from any source for the purpose of determining my eligibility for Medicaid benefits. I authorize this release form to be in effect for as long as I am on Medicaid regardless of the date that it is signed. I further authorize copies of this document to be used in place of the original. I give my consent for the release of information for those purposes directly related to the administration of the Medicaid program. These purposes include, but are not limited to, establishing eligibility for benefits, determination of the amount of medical assistance received, the provision of service and the investigation of program violations.

SIGNATURE(S) I certify that the information I have provided above is true to the best of my knowledge, and I give permission for the State of Mississippi to make any necessary contact to check my statements. I have read the list of my rights and responsibilities that is printed above. If I knowingly give false statements or leave out information asked for on this application, such as income or household members, I commit a crime that is punishable under federal and/or state law. Do you accept these responsibilities and agree to notify the Medicaid Regional Office of any and all changes listed above? Yes No ______________________________________________________________________________________ Signature of 1st Applicant or Legal or Authorized Representative Date ______________________________________________________________________________________ Signature of 2nd Applicant or Legal or Authorized Representative Date ______________________________________________________________________________________ Signature of Non-Applicant Spouse or Parent (if appropriate) Date ______________________________________________________________________________________ Signature of Witness if anyone signs with a mark Date

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3. SPOUSE OR PARENT INFORMATION - Provide the following information for the spouse of the applicant or information on the parent applying for a minor disabled child. The spouse of Applicant #1 may also apply by completing this entire section.Full Name of Spouse or Parent ________________________________________________________________________

What is the language most spoken in your home: For Regional Office Use Only: LTC Facility: OffOther: OffHCBS Waiver Type: Offundefined: Healthier MS Waiver: OffMedicare Cost Sharing: OffDCLH: OffWorking Disabled: OffSSI Retro: OffDeemed SSI: Offundefined_2: Worker: Date Place of Interview: Case Name: Case Number: Spouse Case Name: Case Number_2: Rights Responsibilities explained at time of interview: OffProgrammatic Pamphlets provided: OffYes_3: OffNo If yes provide the following information: OffName of Medicaid Planner: Contact Information for Planner: Name Applicants Using Medicaid Planner Service: Applicants Full Name: Date of Birth Mo: Social Security Number: undefined_3: undefined_4: Day: Year: Single: OffMarried: OffSeparated: OffWidowed: OffDivorced: OffMale: OffFemale: OffWhite: OffBlack: OffAmerican Indian or Alaska Native: OffChinese: OffAsian Indian: OffFilipino: OffJapanese: OffKorean: OffVietnamese: OffOther Asian: OffNative Hawaiian: OffSamoan: OffGuamanian or Chamorro: OffOther Pacific Islander: Offundefined_5: OffOther_2: If HispanicLatino check all that apply optional: OffCuban: OffMexican: OffMexicanAmerican: OffChicanoa: OffPuerto Rican: OffOther_3: age 65 or over: Offblindness: Offdisability describe the: Offdisability: in own home: Offrental home or apt: Offwith someone in their home please list whose: Offhome: nursing facility: Offundefined_6: Offother: Telephone Home: Cell: Other_4: Does applicant plan to enter a nursing facility: OffIf yes when: Enter name location of nursing facility: a hospital: Offhome_2: Offundefined_7: Offother_2: Home Address: Apt or Lot: City: County: State: Zip: Who lives at this address now 1: Who lives at this address now 2: Mailing Address if different: City_2: County_2: State_2: Zip_2: Yes_5: Offundefined_8: OffNo If no when did applicant enter the US: If not a US citizen is applicant in a satisfactory immigration status: OffPrevious Marriages Has applicant ever been widowed or divorced: Offthe Health Insurance Claim as shown on the Medicare card: Does applicant have other health insurance: OffInsurance Company: Group or Policy: Begin Date: End Date if ending: Does applicant receive Medicaid from another state: OffName of State: Date Medicaid will close: Legal Representative Does this applicant have a court appointed guardian or conservator: OffHas this applicant appointed Power of Attorney to anyone: OffNameAddress: Phone s: Relationship to Applicant: Yes_14: OffNo A representative acts in the applicants behalf on matters: OffNameAddress_2: Phone s_2: Relationship to Applicant_2: Full Name of Spouse or Parent: Social Security Number_2: undefined_9: undefined_10: Date of Birth Mo_2: Day_2: Year_2: Single_2: OffMarried_2: OffSeparated_2: OffWidowed_2: OffDivorced Gender: OffMale_2: OffFemale_2: OffWhite_2: OffBlack_2: OffAmerican Indian or Alaska Native_2: OffChinese_2: OffAsian Indian_2: OffFilipino_2: OffJapanese_2: OffKorean_2: OffVietnamese_2: OffOther Asian_2: OffNative Hawaiian_2: OffSamoan_2: OffGuamanian or Chamorro_2: OffOther Pacific Islander_2: Offundefined_11: OffOther_5: If HispanicLatino check all that apply optional_2: OffCuban_2: OffMexican_2: OffMexicanAmerican_2: OffChicanoa_2: OffPuerto Rican_2: OffOther_6: Telephone Home_2: Cell_2: Other_7: Home Address if different from Applicant 1: Apt or Lot_2: City_3: County_3: State_3: Zip_3: Mailing Address if different from above: City_4: County_4: State_4: Zip_4: Who lives at this address now: Is spouse applying for Medicaid on this application: Offage 65 or over_2: Offblindness_2: Offdisability describe the_2: Offdisability_2: in own home_2: Offrental home or apt_2: Offwith someone in their home please list: Offwhose home: nursing facility_2: Offundefined_12: Offother_3: Does Applicant 2 plan to enter a nursing facility: OffIf yes when_2: Enter name location of nursing facility_2: a hospital_2: Offhome_3: Offundefined_13: Offother_4: Is Applicant 2 a US citizen: OffIf no when did spouse enter the US: Yes_18: OffNo Not required: OffYes_19: OffNo If yes enter: Offenter the Health Insurance Claim as shown on the Medicare card: Does Applicant 2 have other health insurance: OffInsurance Company_2: Group or Policy_2: Begin Date_2: End Date if ending_2: Does Applicant 2 receive Medicaid from another state: OffName of State_2: Date Medicaid will close_2: Legal Representative Does Applicant 2 have a court appointed guardian or conservator: OffHas Applicant 2 appointed Power of Attorney to anyone: OffNameAddress_3: Phone s_3: Relationship to Applicant_3: Yes_26: OffNo A representative acts in the applicants behalf on matters_2: OffNameAddress_4: Phone s_4: Relationship to Applicant_4: Does Applicant 1 want to apply for retroactive Medicaid: Yes_27: OffNo If yes enter months needed: OffYes_28: OffNo If yes enter months needed_2: OffVETERAN STATUS: Is Applicant 1 a veteran: Offnot: OffIs Applicant 2 a veteran: Offnot_2: OffIs Applicant a dependent of a veteran: OffName of Veteran: Relationship to Applicant_5: Dates of Service: Branch of Service: I will provide parental financial information so that my child can be considered under any and all: OffI elect to have my childs eligibility considered only under the Disabled Child Living AtHome: OffDoes applicant spouse applying or not or parents of a minor disabled child work: OffIf yes name persons working: Name of Employers: Total wages before deductions: How often paid: If paid weekly or biweekly what is day of week paid: employed during the last 12 months: Offemployed: Type of business: End Date if not active: of a minor disabled child Provide employers name and ending date of employment: Did applicant spouse or parents file a federal tax return last year: OffYes_39: OffNo If so name the: OffIncome of a child not applying for Medicaid is used to determine how much of a nonapplying spouses or parents: the community spouse: Offtherapy: OffIf yes what are the monthly earnings: How Often ReceivedSocial Security: fill_35: fill_36: fill_37: fill_38: How Often ReceivedSSI: fill_39: fill_40: fill_41: fill_42: How Often ReceivedRailroad Retirement: fill_43: fill_44: fill_45: fill_46: How Often ReceivedVA Pension: fill_47: fill_48: fill_49: fill_50: How Often ReceivedVA Compensation: fill_51: fill_52: fill_53: fill_54: How Often ReceivedOther VA Benefits: fill_55: fill_56: fill_57: fill_58: How Often ReceivedMilitary Retirement: fill_59: fill_60: fill_61: fill_62: How Often ReceivedState Retirement: fill_63: fill_64: fill_65: fill_66: How Often ReceivedFederal Civil Service: fill_67: fill_68: fill_69: fill_70: How Often ReceivedMunicipal Retirement: fill_71: fill_72: fill_73: fill_74: How Often ReceivedPrivate Pension: fill_75: fill_76: fill_77: fill_78: How Often ReceivedUnemployment Compensation: fill_79: fill_80: fill_81: fill_82: How Often ReceivedRental Income: fill_83: fill_84: fill_85: fill_86: How Often ReceivedWorkers Comp: fill_87: fill_88: fill_89: fill_90: How Often ReceivedIRA Income: fill_91: fill_92: fill_93: fill_94: How Often ReceivedAnnuity Income: fill_95: fill_96: fill_97: fill_98: How Often ReceivedInterest Income: fill_99: fill_100: fill_101: fill_102: How Often ReceivedTrust Income: fill_103: fill_104: fill_105: fill_106: How Often ReceivedDividends: fill_107: fill_108: fill_109: fill_110: How Often ReceivedPromissory Note Income: fill_111: fill_112: fill_113: fill_114: How Often ReceivedOil Gas or Mineral or Timber Leases: fill_115: fill_116: fill_117: fill_118: How Often ReceivedGovernment Payments on Land: fill_119: fill_120: fill_121: fill_122: How Often ReceivedRoyalties: fill_123: fill_124: fill_125: fill_126: How Often ReceivedChild Support: fill_127: fill_128: fill_129: fill_130: How Often ReceivedAlimony: fill_131: fill_132: fill_133: fill_134: How Often ReceivedCash Contributions: fill_135: fill_136: fill_137: fill_138: How Often ReceivedPublic Assistance TANF or other: fill_139: fill_140: fill_141: fill_142: How Often ReceivedOther specify: fill_143: fill_144: fill_145: fill_146: How Often ReceivedOther specify_2: fill_147: fill_148: fill_149: fill_150: applicant or spouse given away any income or the rights to income or the right to receive income within 5: OffNo If yes verification will be required for all transfers of income: Offeligibility purposes but you must tell us about all resources Enter requested information below: OffYes_42: OffNo If yes enter StateCounty of Home: AddressCity: If ownership is shared who else is on the deed: Yes_43: Offundefined_15: OffNo If yes who: Yes_44: Offundefined_16: OffNo Is yes explain: Is the home being rented or does it produce income: Amount of rental income: Yes_45: Offundefined_17: OffNo If yes what is owed: Does applicant have a reverse mortgage: OffIf yes what are payments: Other Real Property: OffIf yes number of other properties: Location of Each Property City County StateRow1: Type of Ownership Name on DeedRow1: Who Lives on PropertyRow1: fill_30: Location of Each Property City County StateRow2: Type of Ownership Name on DeedRow2: Who Lives on PropertyRow2: fill_31: Location of Each Property City County StateRow3: Type of Ownership Name on DeedRow3: Who Lives on PropertyRow3: fill_32: Location of Each Property City County StateRow4: Type of Ownership Name on DeedRow4: Who Lives on PropertyRow4: fill_33: Location of Each Property City County StateRow5: Type of Ownership Name on DeedRow5: Who Lives on PropertyRow5: fill_34: Does applicant own a mobile home: Offlocated: Yes_49: OffNo If yes give dates and describe the property that was sold or transferred: OffCopies of deeds showing current ownership or ownership at the time property was sold or transferred will be: Cash on Hand Does applicant spouse or parents keep cash on hand greater than 200 spending: money: OffChecking Accounts: OffDirect Deposit Debit Card Account: OffSavings Accounts: OffCDs: OffConservatorship Account: OffFunds Held in a Bank Account Owned by Another: OffFund Raiser Account: OffIRA: OffAnnuity: OffSafety Deposit Box: OffCollege Savings Fund: OffName of BankRow1: Type of AccountRow1: Account NumberRow1: Names on AccountRow1: Current BalanceRow1: Name of BankRow2: Type of AccountRow2: Account NumberRow2: Names on AccountRow2: Current BalanceRow2: Name of BankRow3: Type of AccountRow3: Account NumberRow3: Names on AccountRow3: Current BalanceRow3: Name of BankRow4: Type of AccountRow4: Account NumberRow4: Names on AccountRow4: Current BalanceRow4: Name of BankRow5: Type of AccountRow5: Account NumberRow5: Names on AccountRow5: Current BalanceRow5: Name of BankRow6: Type of AccountRow6: Account NumberRow6: Names on AccountRow6: Current BalanceRow6: If applicant is in a nursing facility is there a patient account at the facility: OffYes_52: OffNo If yes explain: Offyears: plan IRA annuity or other type of fund: Offbeen requested: OffIs the owner of these funds still employed working: Annuities Does applicant spouse or parents own individually or jointly an annuity: OffIf yes name owners: Initial investment: Date purchased: Name annuitant: Yes_57: OffNo Are payments based on entire investment: OffEach annuity must be verified by providing the annuity contract Other information may also be required: OffTrust Funds Is the applicant spouse or parents the beneficiary of a trust: OffTrustees nameaddresstelephone: Has a trust been set up using assets belonging to the applicant spouse or parents: Offagreement for repayment of money loaned or property sold: OffBalance of Loan: Income Received: How Often: Stocks: OffMutual Fund Shares: OffCorporate Bonds: OffMunicipal Bonds: OffGovernment BondsUS Securities: OffUS Savings Bonds: OffForeign Investments: OffOther_8: OffEnter information for each investment owned: Type of InvestmentRow1: OwnersRow1: fill_28: Type of InvestmentRow2: OwnersRow2: fill_29: Type of VehicleRow1: OwnersRow1_2: ModelYearRow1: Amount OwedRow1: Type of VehicleRow2: OwnersRow2_2: ModelYearRow2: Amount OwedRow2: Type of VehicleRow3: OwnersRow3: ModelYearRow3: Amount OwedRow3: antiques or other collectables of substantial value Does applicant spouse or parents own any personal: Offproperty of this type: Describe and give value: Life Insurance Does applicant spouse or parents own life insurance: OffOwnerRow1: InsuredRow1: Face ValueRow1: Insurance CoRow1: undefined_20: Offundefined_21: OffOwnerRow2: InsuredRow2: Face ValueRow2: Insurance CoRow2: undefined_22: Offundefined_23: OffOwnerRow3: InsuredRow3: Face ValueRow3: Insurance CoRow3: undefined_24: Offundefined_25: OffBurial Insurance: OffPreNeed Contract With Funeral Home: Offundefined_26: OffYes_64: OffNo If yes: OffHow are funds set up: Other specify: Verification of the value of the funds and whether funds are accessible may be required: OffNo_46: OffBurial Spaces Does applicant spouse or parents own burial plots or spaces: Yes_65: Are all gravesites used intended for use by family members of applicant: OffOther Are there any other resources owned or being bought by the applicant spouse or parents that: Offare not shown above in the Resource section: within 5 years of this application that have not already been disclosed on this application: OffNo If yes specify: OffYes_68: 8 STATEMENT OF RESIDENCY Does Applicant 1 plan to remain in Mississippi: OffDoes Applicant 2 plan to remain in Mississippi: OffDo you accept these responsibilities and agree to notify the Medicaid Regional Office of any and all: OffDate: Date_2: Date_3: Date_4: Special Needs: Other Special Needs: Former Spouse 2: Former Spouse 1: Former Spouse 3: How Long Married 2: How Long Married 1: How Long Married 3: Married 2: Married 1: Married 3: Name of Applicants: SSNs: Former 1: How Long 1: Ended 1: Former 2: Former 3: How Long 2: How Long 3: Ended 2: Ended 3: Part A: OffPart B: OffSpouse Part A: OffSpouse Part B: OffApp 1 VA Benefits: OffApp 2 VA Benefits: OffPage 9 Working: Off