Form Sfn 958 - Health Care Application For The Elderly And Disabled
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10HEALTH CARE APPLICATION FOR THE ELDERLY AND DISABLED
AGENCY USE ONLY
Case Number:
Date Requested:
SFN 958 (4-2017)
Date Received:
Interview Date:
If you are not elderly or disabled and wish to apply for
Health Care Coverage, complete the Application for
Case Number:
Health Care Coverage (SFN 1909) or the Application for
Assistance (SFN 405).
Instructions For Application For Health Care Coverage
This application may be used to apply for Health Care Coverage, the Medicare Savings Programs, Aid
to the Blind, or Basic Care. See the Guidebook for more information.
What Do I Need to Do to Get Health Care Coverage?
Follow these steps to apply for Health Care:
Check the assistance for which you are applying
(Check ALL that apply).
Step 1:
If you would like more information on these programs, see the Application for
Assistance Guidebook. If you did not receive the Guidebook, contact your local social
service office.
Health Care Coverage –
Medicaid coverage for the elderly and disabled.
Aid to the Blind –
Assists with treatment for people who are not eligible for Medicaid and are
in danger of losing their vision or require restorative eye services.
Medicare Savings Programs –
Assists with Medicare Part B premium, coinsurance
and deductibles.
Basic Care Assistance –
Helps pay for room and board and personal care in licensed
basic care facilities.
Step 2:
Answer as many questions as you can.
If you need help applying for
assistance, you may have a friend, relative, or someone else help you apply. Your local
county social service office can also help you apply for assistance. If you need additional
space, attach a separate sheet of paper.
Step 3:
Sign and Return
the completed application to your local county social service office.
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Parent category: Medical