Form Dma-5007mr - Redetermination For Aged, Blind, And Disabled Adult Categories And/or Family Planning Waiver Services - 2007
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4MEDICAL ASSISTANCE – REDETERMINATION
FOR AGED, BLIND, AND DISABLED ADULT CATEGORIES AND/OR FAMILY PLANNING WAIVER SERVICES
MCDOWELL
____________________County Department of Social Services
Date__________________________
_______________________________________
_______________________________________
_______________________________________
You must complete this form and return any requested information to our agency by __________________or your
Medicaid for _____________________________________________________________________________will stop.
1. Please give a telephone number where you can be reached during the day ___________________________. If you are acting on behalf
of the person listed for the Medicaid review, please answer all questions as he/she would and tell us your relationship to
him/her:_________________________________________________________________________________________________
2. Do you speak English?
YES
NO What language do you prefer to speak? _________________________________
3. Please check the type of income received and tell us the amount.
Social Security $ _____________
Veterans Benefits $ ____________
Annuities $ ___________
Other income or check(s) (Amount) $_________________Type of Income/Check__________________________________
4. List any other money received since the last review.______________________________________________________________
5. How much cash do you have? (If you are in a nursing home, how much is in your patient account?) $______________________
6. Do any relatives live with you and depend on you (or your spouse) to provide at least one-half of their financial support?
YES
NO
If yes, who? ___________________________________________Relationship____________________
7. List the name and age of every person that lives in your home with you and explain how they are related to you.
________________________________________________________________________________________________________
________________________________________________________________________________________________________
8. Do you or your spouse have Medicare or a Medicare HMO?
YES
NO
If Yes, which ones?
_________________________________________________________ Medicare Claim #(s)______________________________
9. Are you or your spouse enrolled in a Medicare Prescription Drug Plan?
YES
NO
If yes, the plan(s) you are enrolled
___________________________________________________________________ ______________
with.
10. Have you bought or dropped any health or medical insurance since the last review or your application?
YES
No
If yes,
Company Name &Address:______________________________________________________ Phone Number_______________
Policy Number: ____________Policy Holder’s (Owner’s) Name: _______________________ Date of Birth ________________
Relationship: ________________________Name of Insured: _____________________________________________________
11. Your records show you have the following bank accounts:
Checking at ________________
Savings at _____________
Do you still have the same accounts?
YES
NO
If no, please tell us what happened to the
accounts.________________________________________________________________________________________________
DMA-5007MR 12-07
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Parent category: Medical