Form Dma-5007mr - Redetermination For Aged, Blind, And Disabled Adult Categories And/or Family Planning Waiver Services - 2007 Page 2
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412. Do you have other accounts anywhere?
YES
NO
If yes, list the name and location of the bank and the account
number.
Name of Bank_____________________Address___________________________Account #____________
(PLEASE SEND YOUR MOST RECENT BANK STATEMENT FOR ALL ACCOUNTS.)
13. Your record shows you have the following motor vehicles:_________________________________________________________
Do you still have all of them?
YES
NO
If you don’t, please tell us what happened. ________________
________________________________________________________________________________________________________
14. Your record shows that you have the following life insurance policies: _______________________________________________
________________________________________________________________________________________________________
Do you still have these life insurance policies?
YES
NO If no, what happened to them?____________________
15. Do you have any new life insurance policies?
YES
NO If yes, write the company name and policy number.
Company Name: __________________________________________ Address: ________________________________________
Phone No.: _________________________________________ Policy #:_____________________________________________
Owner of Policy: _________________________________________________________________________________________
Cash Value: $_________________________________ Face Value: $_______________________________________________
16. List the address of any land or buildings you own: _______________________________________________________________
________________________________________________________________________________________________________
17. Have you received any sums of money, land, or houses since your last review?
YES
NO
If yes, explain:____________________________________________________________________________________________
18. Have you given away any sums of money, land or houses since your last review?
YES
NO
If yes, explain:____________________________________________________________________________________________
19. Does anyone give you money, or provide you with food or a place to live?
YES
NO
If yes, explain:____________________________________________________________________________________________
Complete Only if the Medicaid Recipient Lives in a Nursing Facility
1. If the Medicaid recipient has a legal spouse at home who is allowed to keep some or all of the Medicaid recipient’s monthly income, list
any changes in the income of the at home spouse. ______________________________________________________
________________________________________________________________________________________________________
Medicaid Family Planning Waiver Services
To be eligible for Medicaid Family Planning Waiver services, you must be a woman age 19 through 55 or a man age 19 through 60 and have not had
a medical procedure that would prevent you from having a baby or fathering a baby. If you are found to be ineligible for full Medicaid, but eligible
for FPW, the FPW Medicaid is authorized for 12 months. You are “locked in” to this 12 month period. If you later reapply for full Medicaid
during this 12 month period, your eligibility will be determined based on this certification period. Medicaid may or may not be authorized
based on these requests. Medicare recipients are ineligible for Medicaid Family Planning Waiver services.
Do you wish to apply for Medicaid Family Planning Waiver?
YES
NO
If yes, for whom:___________________________________________________________Social Security #:________________________________
If you are unable to provide the information we asked for, OR if you do not understand a question OR if you would rather have an
office visit for the form to be completed for you, CONTACT ME at _______________________________________.
_______________________________________
Medicaid Caseworker
DMA-5007MR 12-07
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