Resource Assessment Form Page 4
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4LIFE INSURANCE - COMPLETE THE INFORMATION BELOW FOR EACH LIFE INSURANCE POLICY
NAME OF INSURED
INSURANCE
POLICY
NAME OF
FACE
CASH*
DATE
DOCUMENTED
COMPANY
NUMBER
BENEFICIARY
VALUE
VALUE
ACQUIRED
YES
NO
*As of the date of admission to the facility or assessment for HCBS.
NOTES/INFORMATION SECTION -- USE ADDITIONAL SHEET(S) IF NECESSARY
LIST ANY PRIOR ADMISSION TO A FACILITY OR ASSESSMENT FOR HCBS
=
DATE OF ADMISSION OR
NAME AND
=
ASSESSMENT FOR HCBS
ADDRESS OF
LTC SERvICE PROvIDER
=
DATE OF ADMISSION OR
NAME AND
=
ASSESSMENT FOR HCBS
ADDRESS OF
LTC SERvICE PROvIDER
LEGAL REPRESENTATION
DOES THE INDIVIDUAL HAVE A LEGAL REPRESENTATIVE OTHER THAN THE SPOUSE
£
YES
£
NO
(e.g. Court-appointed Guardian, Power-of-Attorney, etc.)
NAME
=
TELEPHONE
IF
NUMBER
YES
STREET ADDRESS
CITY
STATE
ZIP CODE
RELATIONSHIP OF RESIDENT
NOTE: YOUR LEGAL REPRESENTATIVE WILL BE SENT A COPY OF THE RESULTS OF THE RESOURCE ASSESSMENT.
I swear or affirm that all of the information I have provided on this form is true and correct to the best of my ability, knowledge and belief.
SIGNATURE
DATE
RELATIONSHIP TO INDIVIDUAL IN NEED OF LTC SERVICE
CHECKLIST
1.
DID YOU COMPLETE THE INFORMATION FOR THE INDIVIDUAL IN NEED OF LTC SERVICES?
2.
DID YOU COMPLETE THE INFORMATION FOR THE COMMUNITY SPOUSE?
3.
DID YOU LIST ALL RESOURCES OWNED ON THE DATE OF ADMISSION OR ASSESSMENT FOR HCBS?
4.
DID YOU COMPLETE THE LIFE INSURANCE SECTION?
5.
DID YOU READ THE STATEMENT REGARDING THE INFORMATION YOU PROVIDED? DID YOU SIGN THE FORM, INDICATE
YOUR RELATIONSHIP TO THE INDIVIDUAL IN NEED OF LTC SERVICES AND DATE THE FORM?
6.
DID YOU ATTACH PHOTOCOPIES OF THE DOCUMENTATION TO VERIFY YOUR RESOURCES?
FOR DPW USE ONLY
TOTAL VERIFIED COUNTABLE RESOURCES
$ __________________
SPOUSE’S SHARE 1/2 TOTAL NET VERIFIED RESOURCES
$ __________________
ASSESSOR’S SIGNATURE
DATE
NOTICE
=
LEGAL
INDIvIDUAL RECEIvING LTC
SENT TO
SPOUSE
REPRESENTATIvE
SERvICES
YES
NO
YES
NO
YES
NO
PA 1572 2/11
-4-
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