Dhhs Form 3401 - Application For Nursing Home, Residential Or In-Home Care

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Application for Nursing Home,

Residential or In-Home Care

This application is used to apply for Nursing Home, Waiver Services, or O

at the South Carolina

ptional

tate

upplementation (OSS)

Department of Health and Human Services (SCDHHS). Please answer all questions as completely as possible as they apply to you or the

persons for whom you are applying. If you need help filling out this application, you can call

1-888-549-0820.

I am applying for:

Nursing Home

OSS

Waiver Services

Presumptive Disability

This box for pilot use only

Who?

Federal law requires that anyone who applies for Medicaid for themselves must tell us about their citizenship or immigration status and provide or apply

for a Social Security Number (SSN). We can help you apply for a SSN, and benefits will not be denied or delayed while the application is being

processed. SSNs provided will be used to help the State agency determine eligibility. Each non-citizen applying for full Medicaid benefits must provide

United States Citizenship and Immigration Services (USCIS) documents, such as an I-551 (Green Card) or I-94. Anyone applying as a non-citizen for

emergency services only is not required to provide USCIS documents or a SSN.

Some family members of applicants may choose not to apply for Medicaid. In that case, they do not have to provide a SSN or citizenship or immigration

status but will be required to provide information about their income and assets. Benefits to applicants will not be delayed or denied just because some

family members do not wish to apply for themselves. Even though a person not applying for Medicaid is not required to provide a SSN, it is helpful for us

to have this number as we gather the information we need to make a decision. We use SSN to help us check identity, verify eligibility and prevent fraud.

We exchange information with other agencies according to Federal rules and to manage our programs.

How do I apply for benefits?

 You must fill out this application using Black or Blue ink or by Typing your answers. You are also able to apply online by going to

 Attach extra sheets if you need more space to answer any of the questions.

 You may mail your application to: SCDHHS PO Box 100101 Columbia, SC 29202-3031.

 To be valid, the application must have your name, contact information and be signed.

 If we do not have everything we need, you will get a list of what you need to send us.

 When we have everything we need, a decision will be made about your Medicaid eligibility. You should receive a letter within 45 days from the date we

receive your application to tell you if you are eligible. If you need a disability determination, it may take up to 90 days.

 Immediately report any change in income or other information on your application to your local Medicaid office or by calling the call center at 1-888-549-0820.

 We may share this information with other Federal and state agencies as we gather what we need to make a decision.

DHHS Form 3401 (June 2016)

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