Bhsf Form 2-L (Nf) - Medicaid Renewal Form For Nursing Home/group Home Care (Page 6 of 9) in pdf

Bhsf Form 2-L (Nf) - Medicaid Renewal Form For Nursing Home/group Home Care Page 6

Documents of Proof We May Need From You

If someone from Medicaid interviewed you, then…

Please send the documents of proof marked with a check  to the Medicaid office at:

You may keep this page.

If you filled out the renewal form, then…

Keep in mind not everything will apply. To help you decide what to send, enter a check  next to

each document of proof you think does apply. You may keep this page.

Let us know if you do not have or cannot get any of these documents of proof, because we may be

able to get them or help you get them. Please trust that the information you give us on this form and

everything you send us will be kept confidential. We are required by law to keep it private.

See



What to send:

Question

Proof of health insurance premium amount.

Proof of income such as the 1099 from the last tax year, a check stub, or award letter

showing amount of gross income (before withholdings) from retirement, pension, a

job, Veteran’s Benefits, annuities, mineral rights, worker’s comp, child support,

reverse annuity mortgages, and royalties.

Proof of any lump sum payments received in the last year from an insurance or lawsuit

settlement, inheritance, worker’s comp settlement, or Social Security.

Proof of ownership and value for any new assets/resources.

If the person getting Medicaid has a home and they rent it to someone, send proof of

the amount of rental income received (letter from renters or cancelled check) and

proof of the expenses of the rental property.

Other:

Bhsf Form 2-L (Nf) - Medicaid Renewal Form For Nursing Home/group Home Care Page 6