Fillable Resource Assessment Form printable pdf download

PART 4

Instructions for Completing Resource Assessment Form, PA 1572

(To be used by a couple when one of them is in a nursing facility, other medical institution or assessed

eligible for Home and Community Based Services (HCBS), and the other lives in the community.)

Important information for nursing facility residents and their spouses. If you need this information in another language or someone to interpret it, please notify the nursing

facility or contact your local County Assistance Office. Language assistance will be provided free of charge.

Información importante para los residentes en hogares de ancianos y sus esposos. Si usted necesita esta información en otro idioma o alguien que se la traduzca, favor de

notificar al personal de la residencia o comunicarse con la oficina local de Asistencia del Condado (CAO). Asistencia lingüística será proveída gratis.

Thoâ n g tin quan troï n g veà cô sôû döôõ n g laõ o daø n h cho thöôø n g truù nhaâ n vaø vò

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bdak/n

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这是发给疗养所的居民及其配偶的重要通知。如果您需要此通

phoá i ngaã u . Neá u quí vò caà n thoâ n g tin naø y baè n g moä t thöù tieá n g khaù c hay moä t

¨bBnì r bs’ e K. ebI e lakG~ k ¨tU v karBtá m anenHCaPasaep§geTot

知翻译成其他语种或需要为您提供翻译，请通知疗养所或联系

phieâ n dòch vieâ n , xin thoâ n g baù o cho cô sôû döôõ n g laõ o hay lieâ n laï c vôù i Vaê n

Phoø n g Trôï Caá p Quaä n Haï t . Trôï giuù p veà ngoâ n ngöõ seõ ñöôï c cung caá p mieã n

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kNam eGaybkE¨beGay smCrabmNl Klanbdak/nbdaykar

~ a k’

您所在地区的郡县协助办事处(County Assistance Office)。可提

phí.

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lEhrbselakGk. CnY y k~

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供免费语言协助。

Важные сведения относительно жителей домов престарелых и их

p‘ l ’ e Gayeday²tKi

t«f

Â .

супруг (супругов). Если вам нужен данный документ на другом языке

или его устный перевод, обращайтесь в дом престарелых либо в

местное Бюро помощи (County Assistance Office). Помощь переводчика

предоставляется бесплатно.

The Medical Assistance Program - known as

A community spouse may keep a minimum amount

MA - helps meet the medical costs of individuals in

of resources, or one-half of the couple’s combined

need of payment of Long Term Care (LTC) services.

countable resources, up to a maximum amount. Some

Generally, an individual must use most of his own

resources do not affect the determination of the protected

resources and income before Medical Assistance will

amount. In order to make the determination as to which

help pay for LTC services. There are, however, special

resources do and do not count and the protected amount,

rules (sometimes called the Spousal Impoverishment

it is very important that you list all resources regardless of

Provisions) which recognize the importance of pro-

whether they are wholly owned by one person (e.g., an

tecting a portion of a married couple’s total resources

IRA owned by the community spouse), are owned by both

and evaluating the income needs of the spouse who

spouses, or owned with others. The information on this

remains in the community.

form should reflect the value of the resources as of the

The purpose of this Resource Assessment Form

DATE OF ADMISSION to the nursing facility, or the DATE

is to determine how much of a married couple’s

OF ASSESSMENT for HCBS, NOT the date you fill out

total resources may be protected or set aside for the

this form.

community spouse, and how much, if any, must be

Photocopies verifying all resources MUST be sent

spent before the individual in the nursing facility or

with this form. Do not send original documents as they will

assessed eligible for HCBS may be eligible for Medical

NOT be returned to you. An assessment cannot be com-

Assistance benefits. Completing this form will help

pleted unless all resources are verified and the verification is

you to protect the maximum amount of your resources

submitted with the Resource Assessment Form.

under the law.

Please read and complete this form carefully. Do

The Resource Assessment is not an application

NOT complete shaded areas. Sign the form and review

for Medical Assistance, and you are not obligated to

the checklist to be certain you have provided all necessary

apply for Medical Assistance. If you need help in com

verification. You, your spouse, and if applicable, your legal

pleting this form, your spouse, family member, friend,

representative, will be notified in writing of the amount of

attorney, or legal services agency can help you. If

resources that can be set aside and the amount, if any, that

you or your spouse are over 60 years of age, your

must be spent before you apply for Medical Assistance.

local Area Agency on Aging also can help you. If you

Mail (or deliver) the completed form and verification

need Medical Assistance now, contact your county

to the county assistance office in the county where the

assistance office or your local Area Agency on Aging

nursing facility is located, or you are receiving HCBS. The

BEFORE you fill out this form.

LTC Service Provider can provide you with the address, or

check the telephone book.

PA 1572 2/11

-1-

Resource Assessment Form

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