Application/redetermination For Medicaid For Ssi Recipients Template - Virginia Department Of Social Service - 2003
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1
2COMMONWEALTH OF VIRGINIA
AGENCY USE ONLY
DEPARTMENT OF SOCIAL SERVICES
CASE NAME
LOCALITY
APPLICATION/REDETERMINATION FOR MEDICAID FOR
CASE NUMBER
WORKER
DATE RECEIVED
SSI RECIPIENTS
A. IDENTIFYING INFORMATION
NAME: ________________________________________________ SOCIAL SECURITY #: ____________________ DATE OF BIRTH: ______________
ADDRESS: ________________________________________________________________________ TELEPHONE NUMBER: ____________________
MARITAL STATUS:
NEVER MARRIED _______
MARRIED _______
SEPARATED _______
WIDOWED _______
DIVORCED ______
SEX: ___________
COUNTRY OF ORIGIN: ____________________________________
CITIZEN/ALIEN STATUS: _________________________
LANGUAGE (Enter Code): _____
1 - English
2 - Spanish
3 - Cambodian
4 - Vietnamese
5 - Farsi
6 - Haitian-Creole
7 - Laotian
8 - Chinese
9 - Korean
A - Somali
B - Kurdish
C. - Arabic
F - French
G - German
J - Japanese
O - Other
RACE (Enter Code): __________
1 - White
2 - Black/African-American
3 - American Indian/Alaskan Native
4 - Asian
5 - Native Hawaiian/OtherPacific Islander
6 - American India/Alaskan Native and White
7 - Asian and White
8 - Black/African-American and White
9 - American Indian/Alaskan Native and Black/African-American
A - Asian and Black
B - Other
ETHNICITY (Enter Code): _____
1 - Hispanic or Latino
2 - Not Hispanic or Latino
B. ADDITIONAL INFORMATION
CIRCLE ONE
1.
I AM A RESIDENT OF VIRGINIA.
YES
NO
2.
I RECEIVE A SUPPLEMENTAL SECURITY INCOME (SSI) CHECK.
YES
NO
3.
I OWN, HAVE AN INTEREST IN, OR HAVE INHERITED REAL PROPERTY (LAND OR BUILDINGS).
YES
NO
TYPE OF PROPERTY: _______________________________________________ ACREAGE: ________________
VALUE: $ __________________________________
LOCATION: __________________________________
4.
I HAVE OTHER RESOURCES SUCH AS LIVESTOCK, CAR, TRUCK, CAMPER, MOBILE HOME,RETIREMENT
ACCCOUNT, LIFE INSURANCE, BANK ACCOUNT, STOCKS, BONDS, SAVINGS CERTIFICATES,
PATIENT FUND ACCOUNT, TRUST FUNDS, CASH, BURIAL PLOTS, OR BURIAL ARRANGEMENTS.
YES
NO
RESOURCE: ______________________________________________________ VALUE:____________________
RESOURCE: ______________________________________________________ VALUE:____________________
RESOURCE: ______________________________________________________ VALUE:____________________
5.
I HAVE SOLD, TRADED, OR GIVEN AWAY ASSETS (LAND, BUILDINGS, BANK ACCOUNTS, MONEY,
CARS, STOCKS, TRUST FUNDS, INCOME, ETC.) DURING THE PREVIOUS 60 MONTHS.
YES
NO
WHEN: _______________________________________________
TO WHOM: __________________________
WHAT: _______________________________________________
AMOUNT RECEIVED: $ ________________
6.
I HAVE MEDICARE.
YES
NO
MEDICARE #: ________________________________________________
PART A EFFECTIVE DATE: ______________________
PART B EFFECTIVE DATE: _____________________
7.
I HAVE OTHER HEALTH INSURANCE.
YES
NO
COMPANY NAME: __________________________________________ POLICY #: __________________________
TYPE OF COVERAGE: ______________________________________ EFFECTIVE DATE: ___________________
8.
I LIVE IN A NURSING FACILITY OR STATE INSTITUTION.
YES
NO
IF YOU STILL OWN YOUR HOME, WHO LIVES IN IT. ____________________________________________________
(NAME AND RELATIONSHIP)
10. I RECEIVED MEDICAL CARE DURING THE THREE MONTHS BEFORE THIS APPLICATION.
YES
NO
FROM: _______________________________________________________________ DATE: _____________________
032-03-091/16 (6/03)
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