Bhsf Form 1 Ipc Louisiana

BHSF Form 1-L SSI Rev. 6/11 Louisiana Medicaid Program SSI Recipient Application Long-Term Facility Care Home and Community Based Services HCBS or Program of All Inclusive Care for the Elderly PACE What language do you speak best English Spanish Vietnamese Other specify Name of Applicant person who needs long-term facility care Home and Community Based waiver or PACE. Name First Middle Initial Maiden Last Social Security Date of Birth Marital Status Single Married Divorced Widowed Is the person in need of long term care a Veteran Yes No If yes VA Claim Railroad Retirement Residence address State Zip code Mailing address City Who is the person responsible for handling the applicant s affairs Name Cell phone Daytime phone E-mail address Relationship to the applicant Does this person have power of attorney Yes No If no does someone else have power of attorney Yes No If yes who A. What is the applicant s current facility status Lives in a nursing facility Plans to enter a facility Facility name Date Entered the Facility B. Is the applicant applying for Home and Community Based Services waiver Yes No Has the applicant been offered an opportunity slot for HCBS waiver Yes No What type of HCBS waiver is the applicant applying for Adult Day Health Care Children s Choice Elderly/ Disabled Adult New Opportunities Name of case management agency 4. Did the applicant move to Louisiana from another state Yes No If yes when Does he or she intend to remain in Louisiana Yes No -1- Does the applicant have a legal spouse who lives at home and/or any children under age 18 Yes No If yes give us the following information about these people. apply for Medicaid month day year to Applicant Yes No Yes No What is the source and amount of the income If applying for long-term facility care does the applicant wish to contribute part of this income to the legal spouse and/or any children under age 18 Yes No wages income before any deductions. How often paid Did or will the applicant or the applicant s spouse receive any lump sum of money like an insurance or lawsuit settlement inheritance or retroactive Social Security payment Yes No If yes who From whom Amount For what reason When Name s on the account Name and address of the bank or financial institution Account Number Balance 10. Has the applicant or applicant s spouse ever created a trust placed any items in trust or been named as the beneficiary of a trust Yes No A copy of the trust will need to be provided* 11. Does the applicant or applicant s spouse own or are they buying the home in which they live or any other properties -2- If yes give the following information* Description of the property Amount owed on the property Value of the property Number of other heirs or property Yes No If yes give the following information* What was given away sold or deeded To whom Date visits Yes No If yes give the following information* Group/Policy Monthly Cost If yes amount Policy s Rights and Responsibilities WHAT MEDICAID HAS THE RIGHT TO EXPECT OF YOU the person applying for Medicaid CITIZENSHIP AND IMMIGRATION STATUS You state that the information about citizenship and immigration status given at the beginning of this application form is true and correct.