Medicare Savings Programs Application/redetermination (Qmb, Slmb, Almb)
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6State of Connecticut
Department of Social Services
Medicare Savings Programs Application/Redetermination
W-1QMB
(QMB, SLMB, ALMB)
(Rev. 4/10)
Do you need a reasonable accommodation or special help to complete your application/redetermination because
you have a disability?
Yes
No
If you checked yes, please see page 4 about how we can help.
If you need a reasonable accommodation or special help, what kind of help do you need?
Please give us the following information about you:
Your Name:
First
M.I.
Last
Your Address:
Your Mailing Address (if different):
Your Telephone Number:
A Message Number:
Your Marital Status:
Never Married
Married
Separated
Divorced
Widowed
This application is for
Yourself only
Yourself and your spouse
Your Spouse’s Name
:
First
M.I.
Last
Do you have Medicare?
Social Security
Part A?
Part B?
Date of Birth
Place of Birth
Number
Sex
(check one)
(check one)
Yourself
Yes
No
Yes
No
Your
Spouse
Yes
No
Yes
No
Please tell us about your medical insurance
:
Add separate pages if you need them.
Insurance for Yourself
Insurance for Your Spouse
Medicare Claim #:
Medicare Claim #:
Other Insurance, if any
Other Insurance, if any
Company Name:
Company Name:
Address:
Address:
Customer Service Phone:
Customer Service Phone:
Policy Number:
Policy Number:
Group Number:
Group Number:
Please check off all the services that are covered:
Please check off all the services that are covered:
Hospital
Doctor/Hospital/Surgical
Hospital
Doctor/Hospital/Surgical
Prescription
Vision/Optical
Dental
Prescription
Vision/Optical
Dental
Long Term Care
Long Term Care
Policy Start Date:
Stop Date:
Policy Start Date:
Stop Date:
Policy Premium Amount:
per
Policy Premium Amount:
per
When you started paying this premium:
When you started paying this premium:
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Parent category: Medical