Form Dhmh 4241 (Ssi/ltc) - Notice To Review Medical Assistance Eligibility For Ssi Long Term Care

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MARYLAND MEDICAL ASSISTANCE PROGRAM
NOTICE TO REVIEW MEDICAL ASSISTANCE ELIGIBILITY
FOR SSI LONG TERM CARE
Date:_________________________
RE: __________________________
Client ID #: ____________________
Dear ____________________________________:
This is to notify you that it is time to review Medical Assistance eligibility for the above-named
recipient. Please answer fully the questions below:
□
□
1. Does the recipient still reside in a nursing home?
Yes (go to #3)
No (go to #2)
2. What was the date of discharge or death?___/____/____(Please stop here and return this
form to the local department. If deceased, please send a copy of the death certificate.)
3. What is the name of that nursing home?_______________________________________
4. Who is the recipient’s current authorized representative?
Name:___________________________________Relationship:______________________
Address:__________________________________________________________________
__________________________________________________________________
Home Phone:__________________________ Other Phone:________________________
5. What kind of income does the recipient receive? (Please attach proof(s) of income)
□
□
□
□
SSI
SSDI
Veteran’s
Other___________________________
6. What assets does the recipient own? (bank accounts, life insurance, property, etc.)
(Please attach proof(s) of income)
□
_________________________________
□
_________________________________
□
_________________________________
Please return photocopies of those items with this letter to the local department before ______________.
All Medical Assistance recipients are required to report to their caseworker any changes
concerning their circumstances within 10 business days of the change. This includes, but is not
limited to, changes in income, resources, living arrangements, and home property.
Sincerely,
________________________________
Case Manager
_______________________________
_
Department of Social Services
________________________________
Telephone Number
DHMH 4241 (SSI/LTC) – Revised 12/08
White–Customer/Authorized Representative Copy Yellow-Long Term Care Facility Copy
Pink-Case Record Copy

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