Dhhs Form 3401 - Application For Nursing Home, Residential Or In-Home Care Page 3
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104. Do you or someone you are applying for want nursing home services, either in a nursing home or at home?
.................
Yes
No
If yes, who:
Nursing Home
Services at Home
5. Do you or someone you are applying for want to go into a Residential Care Facility/Boarding Home?
..............................
Yes
No
If yes, who:
6. Are you or someone you are applying for currently in a Hospital, Nursing Home, or Residential Care Facility?
..............
Yes
No, at Home
If yes, who:
Date Entered:
Where:
7. Are you blind, disabled, or applying for someone who is blind or disabled?
.............................................................................
Yes
No
Name of Blind or Disabled Person
Is this Person Receiving or Applying for Social Security or SSI
Receiving Social Security or SSI
Applying for Social Security or SSI
Receiving Social Security or SSI
Applying for Social Security or SSI
8. Have you or someone you are applying for received medical services in the past three months? .........................................
Yes
No
Person(s) Receiving Medical Services
Months Services Received
You will have to give us information about income and assets for each month to see if the person may be Medicaid eligible
9. Did you or someone you are applying for retire from the military, have a service related disability, OR are the spouse or dependent of
someone who has retired from the military or has a service related disability?
........................................................................
Yes
No
If Yes, tell us who?
10. Has the applicant or spouse ever worked somewhere that has a retirement benefit for which he or she may be eligible to receive money?
Yes
No
If yes, who was working, where and for how long?
11. Has anyone in the home stopped working within the past year?
Yes
No If YES, tell us who was working, where, and when the job ended.
DHHS Form 3401 (June 2016)
Page 3 of 9
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