Medicaid Application Checklist Form printable pdf download

Medicaid Application Checklist Form

MEDICAID APPLICATION CHECKLIST

Date: ____________________________

Resident Name: _____________________________________________

Effective Date: _____________________

Please bring in copies of the following information with the Medicaid Application.

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_____ All Insurance Cards – Applicant and Spouse (Medicare, Blue Cross/Blue Shield, Harvard, etc.)

_____ Social Security Card

_____ Birth Certificates

_____ Home Address

_____ Deed

_____ Rental Contract

_____ Utilities Expenses

_____ Income Verification (Social Security check, Pension, Trust, Annuities, etc.)

_____ Tax Returns (three years)

_____ Bank Statements for all accounts (three years)

_____ Life Insurance Policy

_____ Trust

_____ Burial Accounts and Contracts

_____ Motor Vehicles (fair market value, amount owed, etc.)

_____ Stocks/Bonds/Annuities

_____ Signed MassHealth Permission to Share Information Form

_____ Signed MassHealth Eligibility Representative Designation Form

_____ Other: _______________________________________________________________________

____________________________________________________________________________

Please contact Sophia Booz at (978) 443-9000 x209 BEFORE mailing your application.

Admin\medicaidappcklist

Rev: 09/2003

Medicaid Application Checklist Form