Dhhs Form 3401 - Application For Nursing Home, Residential Or In-Home Care Page 8

Download a blank fillable Dhhs Form 3401 - Application For Nursing Home, Residential Or In-Home Care in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Dhhs Form 3401 - Application For Nursing Home, Residential Or In-Home Care with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

24. Has the applicant received an inheritance in the last five years?

Yes

If YES, from whom?

Date of Death:

State/County where estate was probated

Additional inheritance?

If YES, from whom?

Date of Death:

State/County where estate was probated

PLEASE READ THE FOLLOWING RIGHTS AND RESPONSIBILITIES

AND SIGN THE APPLICATION ON PAGE 9

Rights and Responsibilities

Please read the following rights and responsibilities. If you disagree with a statement, your eligibility for programs may be impacted. A signature is required to

complete the application process and submit your application to the agency.

I know that under federal law, discrimination isn’t permitted on the basis of race, color, national origin, sex, age, or disability. I can file a complaint of

discrimination by calling (888) 808-4238 or writing to the Civil Rights Division, SCDHHS, P.O. Box 8206, Columbia, SC 29202-8206.

I know I will be asked to cooperate with the agency that collects medical support from an absent parent. If I think that cooperating to collect medical support

will harm me or my children, I can tell the agency and may not have to cooperate.

I assign and give my rights to any payments from a liable third party to the SCDHHS up to the payment amount that Healthy Connections has made for my

medical care. This assignment applies to any of my minor children who may be injured. These payments may include payments from health insurance, legal

settlements, or other third parties. I also understand that I have a duty to cooperate in identifying and providing information to assist Healthy Connections in

pursuing third parties who may be liable to pay for care and services.

I understand that I must cooperate fully with state and federal workers if my case is reviewed. I also understand that, as a condition of eligibility, I must apply for

and take steps to obtain any other benefits, including but not limited to annuities, pensions, retirement, disability and other benefits.

As an applicant/beneficiary for Medicaid services, I understand that there are two groups of people that are affected by estate recovery:

•

A person of any age who was a patient in a nursing facility, intermediate care facility for the intellectually disabled, or other medical institution at the time of

death, and who was required to pay most of his/her income for the cost of care; or

•

A person who was 55 years of age or older when he/she received medical assistance consisting of nursing facility

services, home and community based services, and hospital and prescription drug services provided to individuals in nursing facilities or receiving home

community-based services.

I understand that upon receiving any of these services, the Department of Health and Human Services will file a claim against my estate (all personal and

real property owned by me at my death) for the amount Medicaid has paid for my services.

DHHS Form 3401 (June 2016)

Page 8 of 9