Healthcare Application For The Elderly And Disabled Page 4
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10SFN 958 (3-2016)
Page 4 of 10
Tell Us About The People In Your Home
Fill in the boxes below for yourself, spouse, if any, and anyone else in your home, including those temporarily out of the home
for work, the military or medical reasons:
If you need additional space, continue on a separate sheet of paper.
Refer to the General Information section of the Application for Assistance Guidebook to determine what information is optional
for you to provide.
Household Members
Relation
Social
Date of
Age
Sex
U. S.
Hispanic
Race
Marital
(Enter Legal Name)
Security
Citizen
or Latino
To You
Birth
Status
Middle
Number
(Yes or
(Yes or
Use
Use
First
Initial
Last
No)
No)
Codes
Codes
Below
Below
Self
Race Codes:
AI - American Indian/Alaska Native
AP - Asian
BL - Black/African American
HP - Native Hawaiian/Pacific Islander
WH - White
Marital Status Codes:
DI - Divorced
MA - Married
NM - Never Married
SE - Separated
WI - Widowed
If you do not want Health Care Coverage for all members of the household listed above, please list members you DO NOT want Health Care
Coverage for:
If you are applying for Health Care Coverage and are an enrolled member in a federally-recognized Indian tribe, you may be eligible for no
enrollment fees or pemium payments under certain Health Care Coverage. Please list enrolled members and their tribal enrollment
numbers:
Tell Us About Your Household
I/We have lived in North Dakota since (month, day, and year):
Do you intend to remain in North Dakota?
Yes
No
List other names that have been used by household members (maiden name, prior married name or nickname):
List household members temporarily out of the home:
Why are they out of the home?
Date Expected to Return:
List household members who are disabled:
If you have recently applied for disability and the decision by the Social Security Administration is still pending please
provide proof of your pending status along with this application.
List household members who have ever served in the military or who was a spouse of someone that served:
Have household members received medical assistance in another state?
Yes
No
If Yes, When?
Which City, County, and State:
If yes, when did/will they start receiving nursing care services?
Does anyone in your household
Yes
No
require nursing care services?
If receiving nursing care services in a facility, which facility?
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Parent category: Medical