Bhsf Form 2-L (Nf) - Medicaid Renewal Form For Nursing Home/group Home Care Page 3
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98. ASSETS / RESOURCES: Fill out the spaces below about the assets of the person who gets
Medicaid and their spouse. (Let us know if they still have these and about new things).
ASSET TYPE
Still Have It
No Longer Have It
New
For each type, answer:
For each type, answer:
When did you or they
Tell us if the person getting
What happened to it?
Answer each
get it?
Medicaid or their spouse has
question below.
How much is it worth?
this item.
When did you or they get
Name of bank or
rid of it?
company.
How much?
Life Insurance, Burial Insurance:
Never had it
No longer have it
Still have it
New: Got it in past year
How much is in the
Bank Account for Burial, Pre-
account/contract?
arranged Burial Contract with
Funeral Home:
Never had it
No longer have it
Still have it
New: Got it in past year
How much is in the
Checking/Savings/Christmas Club
account(s)?
Accounts:
Never had it
No longer have it
Still have it
New: Got it in past year
How much is in the
Patient Fund Account at Nursing
account?
Facility:
Never had it
No longer have it
Still have it
New: Got it in past year
How much is it
Certificates of Deposit (CDs):
worth?
Never had it
No longer have it
Still have it
New: Got it in past year
How much?
How much?
Cash on Hand or Held by
Where did the cash
Someone Else:
come from?
Never had it
No longer have it
Still have it
New: Got it in past year
How much is in the
Annuities, Trusts:
account(s)?
Never had it
No longer have it
Still have it
New: Got it in past year
How much is it
Stocks, Bonds:
worth?
Never had it
No longer have it
Still have it
New: Got it in past year
How much is in the
Retirement Accounts:
account(s)?
Never had it
No longer have it
Still have it
New: Got it in past year
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Parent category: Medical