Dhhs Form 3401 - Application For Nursing Home, Residential Or In-Home Care Page 6

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15. Does anyone have private health insurance, Medicaid from another state (other than SC), or Medicare?

..........................

Yes

Policy Number or

Policy Holder

List everyone covered by the insurance

Name of Insurance Company

Medicare Number

Please include a copy of the front and back of all health insurance cards

If applying for nursing home services, either in a nursing home or at home,

Please answer questions 16 through 24

16. If married and entering a nursing home, does the applicant want to give (allocate) part or all of income to a spouse remaining at home?

......................................................................................................................................................................................................................

Yes

17. If there are dependent children or dependent adult, does the applicant want to give (allocate) income to the dependent children or

dependent adult?

......................................................................................................................................................................................

Yes

18. 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

If yes, who was working, where and for how long?

19. Does anyone have a bank account, or any other asset, for the applicant or spouse?

.............................................................

Yes

If yes, at what bank or location, and in whose name(s)?

20. Has the applicant or spouse closed any bank accounts in the past five (5) years?

..................................................................

Yes

If yes, at what bank and in whose name(s)?

Date Closed:

Closing Balance: