Form Uhss 2.1-1 - Application For Admission (Page 3 of 3) in pdf

Form Uhss 2.1-1 - Application For Admission Page 3

Attachment A

Application for Admission

To Residential Health Care Facilities in

St. Lawrence County

Applicants Name: ______________________________________

Due to Medicaid’s Deficit Reductions Act of 2005, there have been changes evaluating Long Term Care

Medicaid Eligibility. Please respond to the following:

Within the past 5 years has the Applicant had a transfer of any resources or real estate?  Yes  No

Within the past 5 years has the Applicant/Spouse purchased any Life Estates in another individual’s home? Yes No

Within the past 5 years has the Applicant/Spouse purchased a Note, Loan, Mortgage or Annuity?  Yes  No

Does the Applicant/Spouse own real property other than their homestead?  Yes  No

Has the Applicant had a transfer of any resources or real estate in the last 60 months (5 years)?  Yes  No

Does the Applicant have a Trust Fund?  Yes  No If yes, was it established within the last 60 months?  Yes  No

Does the Applicant own their own home?  Yes  No

If the Applicant is the sole owner of their home, is the equity of the said home valued at $750,000 or above? Yes  No

Signature of Applicant or Representative

Date

01/19/15

Form UHSS 2.1-1

Page 3 of 3

Form Uhss 2.1-1 - Application For Admission Page 3