Arkansas Department Of Human Services Long Term Care Application For Assistance Page 8
Download a blank fillable Arkansas Department Of Human Services Long Term Care Application For Assistance in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Arkansas Department Of Human Services Long Term Care Application For Assistance with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6
7
8•
I understand that I must help establish my eligibility by providing as much of the requested information as I can.
•
I authorize the Department of Human Services to make any investigation concerning me and/or my spouse necessary to establish my
eligibility for assistance.
•
I understand that no person may be denied long term care assistance or other Medicaid assistance on the grounds of race, color, sex,
national origin or disability.
•
I understand that I may request a hearing before the state agency representative if a decision is not reached on my case within the
appropriate time limit or if I disagree with the decision reached.
•
I agree to notify the Department of Human Services within 10 days if I or my spouse receive additional income, acquire or dispose of
property or if any other changes occur in my circumstances.
•
I understand that by applying for Medicaid I automatically assign my right to any settlement, judgment or award which may be obtained
against any third party to the Arkansas Department of Human Services to the full extent of any amount which may be paid by Medicaid
for my benefit. I also understand that this assignment is required by Act 463 of 1987.
•
Assignment of Medical Support includes the rights to benefits from hospital/medical insurance, workers compensation, etc.
•
I authorize the Department of Human Services to examine all records of mine, or records of those receiving or having received Medicaid
benefits through me, for the purpose of investigating whether or not any person may have committed Medicaid fraud or for use in any
legal, administrative or judicial proceeding.
•
I understand that I must provide my Social Security Number as a condition of my eligibility; and I understand that this number may be
used by the Agency without my express permission in a computer match to obtain information relative to my eligibility for assistance
from the Social Security Administration, Department of Workforce Services, Internal Revenue Services, or other agencies.
•
I understand the requirement to disclose, in my application for Long Term Care services, information regarding any interest
that I or my community spouse may have in an annuity.
•
I understand the requirement to name the state as a remainder beneficiary in which I or my spouse is the annuitant.
•
If you have questions or problems regarding your application or care, please call your State Long Term Care Ombudsman at
501-682-8952.
•
IMPORTANT ESTATE RECOVERY NOTICE:
If you receive Medicaid in a nursing facility, ICF/MR facility, or under a home and community based waiver program, the total amount of
the Medicaid benefits paid on your behalf will be a debt to DHS and may be recovered from your estate after your death. Your estate is
the property you own at the time of your death. DHS will not make a claim against your estate while you are living. DHS will not make a
claim against your estate after your death if your spouse is still living, or if you have dependent children under age 21 or blind or
disabled children. DHS will collect the debt, if any, by filing a claim in your estate. Collection may not be made if it is not cost effective
to DHS or if your heirs apply for a hardship waiver after your death. A hardship may exist if the estate property is the only source of
income for your heirs, if that income is limited, or if there are other compelling circumstances.
CERTIFICATION: I HAVE READ THE ABOVE STATEMENTS; AND I AGREE TO THEIR PROVISIONS.
•
FOR LONG TERM CARE FACILITY RECIPIENTS/APPLICANTS ONLY: After reviewing the alternatives to nursing facility placement
available through the Department of Human Services, I understand that I am choosing to be served in a nursing facility.
•
I understand that if I am admitted to a nursing facility based on conditional Medicaid approval and my Medicaid case is denied, I, or my
family, will be responsible for any indebtedness while in the nursing facility.
•
I understand that this form is signed subject to penalties for perjury, I understand that if I receive assistance to which I am not entitled as
a result of withholding information or providing inaccurate information, such assistance will be subject to recovery by the Department of
Human Services and I may be subject to prosecution for fraud and fined and/or imprisoned.
Witness (if signed by mark)/Date
Applicant, Guardian, or Authorized Rep’s Signature
Address of Witness/Telephone Number
Date
Telephone Number
Name of Person Who Helped Complete Form/Date
Guardian or Authorized Rep.’s Address
Signature of County Office Worker/Date
DCO-777 (R.11/07)
Page 4 of 4
ADVERTISEMENT
0 votes
Related Articles
Related forms
Minnesota Department Of Human Services 90 Day Transition Plan For Youth Discharged After Age 18
Business
Application For Retroactive Medicaid Coverage - Department Of Human Services - Case Records Management Unit Form
Legal
Personal Care Assistance (pca) Technical Change Request Form - Minnesota Health Care Programs (mhcp) - Minnesota Department Of Human Services
Legal
Form Il444-3455 - Child Care Application - Department Of Human Services - Bureau Of Child Care And Development
Legal
Related Categories
Parent category: Medical