Dhhs Form 3401 - Application For Nursing Home, Residential Or In-Home Care Page 2

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Date Application Received by DHHS:

1. Tell us who is the person that needs help (Applicant) and how we can get in touch.

Name (First, Middle Initial, Last)

County (Where you live)

Do you want to get information about this

application by email?

Yes

E-Mail Address:

Home or Street Address (include apartment or lot number)

City

State

Zip Code

What is your preferred language?

Mailing Address (If different from where you live)

City

State

Zip Code

Spoken

Written

English

Phone Numbers

Spanish

Home:

Work:

Cell:

Other:

This information is Optional for:

Tell us about the person(s) who needs nursing home, long term care, or residential care.

 Anyone not applying for Medicaid coverage;

Please include any dependents the person may have, such as a spouse or children.



A non-citizen applying for Emergency Services Only

See below

Is this

Race

Social Security

Relationship to

Is this

Marital Status

Is this

person

*** (Race

person

Number

the Applicant

Single,

Name

Sex

person a

Date of Birth

applying

codes

applying

Married, Divorced,

(Use Relationship

for

US citizen?

shown

Widowed, Separated

Family

Codes shown below)

Medicaid?

below)

Planning?

Applicant

Male

Yes

Female

Spouse

Male

Yes

Female

Male

Yes

Female

Male

Yes

Female

Male

Yes

Female

* Relationship Codes: SP Spouse

BF/GF Boyfriend/Girlfriend

NR Not Related

OTH Other

CH Child (Natural or Adopted)

SC Step-Child

GC Grandchild

NE Niece/Nephew

*** Race Codes:

01 White/Caucasian

02 Black/African American

03 Multi Race

04 Federally Recognized Native American (Requires Verification)

05 Other Native American

06 Alaska Native

07 Asian

08 Other/Unknown

09 Native Hawaiian/Pacific Islander

10 Hispanic

Family Planning is a limited benefit program, which provides family planning services, family planning-related services and certain limited preventative screenings. Family Planning is not full Medicaid coverage. If you

leave this question blank, we will not assess you for Family Planning.

3. Please tell us if anyone has Conservatorship, Guardianship, or Power of Attorney for the applicant.

If yes, please give us a copy of the legal or court papers and the name and phone number of the person.

Conservatorship

Name and Phone Number:

Guardianship

Name and Phone Number:

Power of Attorney

Name and Phone Number:

DHHS Form 3401 (June 2016)

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