Maryland Department Of Human Resources
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1
2Bureau of Long Term Care
910 Frederick Rd
Catonsville, MD 21228
MARYLAND DEPARTMENT OF HUMAN RESOURCES
Family Investment Administration
Long Term Care Medical Assistance
Request for Information to Verify Eligibility
Local Department:
Date:
Case Name:
Address:
Address:
CID#:
(Please use this number on all correspondence)
:
Case Manager
Telephone Number:
Ms./Mr:____________________________________
for:_____________________________________
After you give us a signed application, we have 30 days to make a decision about eligibility for Long Term
Care Medical Assistance. To make that decision, we must have the verifications checked NEED.
Please mail or bring them to our office at the address above by _______________. Please keep copies of all
information that you supply.
Questions? Would you like an in-person meeting? Call your case manager at the number above.
Key: N/A - Not Applicable
OK - Already have or do not need
NEED - Please Provide
I.
BASIC REQUIREMENTS
N/A OK
NEED
Signed, dated application (DHR/FIA CARES 9709)
Consent to Release Information - Nursing home to DSS worker (DES 2002 form)
Consent to Release Information - DSS worker to nursing home (DES 2005 form)
DHMH 257 (Medical certification initiated by Nursing Facility)
II.
DEMOGRAPHIC DATA
N/A OK NEED
ber
Proof of Social Security Num
(SSA 1099, SSA letter, or other SSA verification)
Medicare Card (front and back of the card)
Alien status
(
Proof of disability
DHR/FIA 700, DHR/FIA 827, DHR/FIA 3368, if applicable and verification
that the applicant has a pending SSA claim)
Marriage Certificate/Divorce Decree
Spouse’s Death Certificate
III.
INCOME VERIFICATION
N/A OK NEED
Income Tax Returns (IRS, 1-800-908-9946) for the tax year(s) specified___________________
Social Security Benefits (award letter, SSA 1-800-772-1213) For_____________________________
Private Pension (gross benefit/deductions, if any) For_____________________________
Application for any private public benefit to which the applicant may be entitled
Other (annuities, alimony, royalties, income from loans, LTC insurance, etc.)__________________
IV.
ASSETS
Checking, Savings, Certificates of Deposit, Stocks, Bonds, Mutual Funds, etc.
(for the month of application and any additional statements specified)
N/A OK NEED
NAME
ACCT. #
COMMENTS
FOR:
(which months, etc.)
______________ ______________ _____________ ________________
______________ ______________ _____________ ________________
______________ ______________ _____________ ________________
______________ ______________ _____________ ________________
______________ ______________ _____________ ________________
______________ ______________ _____________ _____________
(PLEASE GO TO PAGE 2)
DHR/FIA 1052-LTC Page 1 of 2 (All previous versions are obsolete.)
Original: Representative
Yellow: Long Term Care Facility
Pink: Case Record
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