STATE OF WISCONSIN
AST
DEPARTMENT OF HEALTH SERVICES
Division of Health Care Access and Accountability
F-10095 (07/15)
MEDICAID ASSET ASSESSMENT
MEDICAL INSTITUTION / COMMUNITY WAIVER RESIDENT AND COMMUNITY SPOUSE
Providing or applying for a Social Security Number (SSN) is voluntary; however, any person who wants
Medicaid benefits but does not provide an SSN or apply for one will not be eligible for benefits. SSNs and
personally identifiable information will be used only for the direct administration of the Medicaid Program.
INSTRUCTIONS:
Do not write in shaded areas. “Resident” means the person who resides in a medical institution or is a
community waivers participant.
This form requests information about the property or assets owned by you and/or your spouse. This
information is needed to determine the following:
•
The total amount of assets owned by you (resident) and your spouse,
•
Your spouse’s share of those assets; and
•
The amount of assets you and your spouse may keep and meet the Medicaid asset limit.
Answer the following questions by providing information about all assets owned by you (resident) and/or your
spouse as of ________________________. Include assets owned jointly with your spouse, family members
or other persons. Include your share and/or your spouse’s share of jointly owned assets. You may be asked
to verify some or all of the information you provide.
Case Name
Case Number
County
Worker Name
SECTION I – MEDICAL INSTITUTION / COMMUNITY WAIVER RESIDENT INFORMATION
Resident Name (Last, First, MI)
Institution / Community Program Address (Street, City, State, Zip Code)
Resident’s Social Security Number
Resident’s Birthdate (mm/dd/yy)
Resident’s Telephone Number
SECTION II – SPOUSE INFORMATION
Spouse Name (Last, First, MI)
Spouse’s Address (City, State, Zip Code)
Spouse’s Social Security Number (only if applying)
Spouse’s Birthdate (mm/dd/yy)
Spouse’s Telephone Number