Dhs 4574 B Form PDF Details

Navigating healthcare coverage eligibility and asset protection in the event of long-term care involves a series of detailed processes, one of which is the completion of the DHS-4574-B form, mandated by the Michigan Department of Health and Human Services. This particular document serves a critical function—it's an assets declaration for both the patient and, if applicable, their spouse. Its primary aim is to ascertain the eligibility of individuals for healthcare coverage while determining the extent of assets that can be safeguarded for a spouse's benefit. Applicants are required to provide comprehensive details about all assets owned, including those held jointly with others. This encompasses a broad spectrum of assets, from bank accounts and real estate to vehicles, life insurance policies, and even burial plots. Additionally, this form delves into recent transactions that could affect eligibility, such as the sale or gift of significant assets, as well as the existence of any pending lawsuits or one-time payments that might have been received. The grave importance of truthfulness is underscored through an affidavit section, where applicants are reminded of the legal consequences of perjury or fraud. The DHS-4574-B form also introduces applicants to the concept of estate recovery, a process by which the state can reclaim costs from the estate of deceased individuals who received healthcare coverage services. This aspect highlights the complex interplay between asset declaration and the potential long-term implications on an estate, making thorough and accurate completion of the DHS-4574-B form a crucial step for applicants navigating the intersection of healthcare coverage and asset management.

QuestionAnswer
Form NameDhs 4574 B Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesmi asset declaration form, dhs 4574 b form, asset patient form, 4574 b form

Form Preview Example

ASSETS DECLARATION

PATIENT AND SPOUSE

Michigan Department of Health and Human Services

(Skip if no spouse)

FOR OFFICE USE ONLY

Beneiciary Name

Client ID

Case Number

County

District

Section

Unit

Specialist

 

 

 

 

 

PLEASE PRINT

Patient’s Name (First, Middle, Last)

Phone No. of Nursing Home

Spouse’s Name (First, Middle, Last)

Spouse’s Phone No.

 

 

 

 

 

 

 

Address of Nursing Home (Number, Street, Rural Route)

 

Spouse’s Address (Number, Street, Rural Route)

 

 

 

 

 

 

 

City

State

 

Zip Code

City

State

Zip Code

 

 

 

 

 

 

Patient’s Birthdate (Mo/Day/Yr)

Patient’s Social Security

Spouse’s Birthdate (Mo/Day/Yr

Spouse’s Social Security*

 

 

 

 

 

 

 

This form asks questions about the property or assets owned by you and/or your spouse. This information is needed to determine your eligibility for Healthcare Coverage and the amount of assets that can be protected for the beneit of your spouse. Answer the following questions by providing information about all assets owned by you and/or your spouse as of _________________________.

Include assets you or your spouse own jointly with family or other persons.

ASSETS

1. Do you and/or your spouse have any assets (include assets held jointly)?

 

c Yes

4Check all types of assets your household has and complete the table

c No

c c c

Checking/draft account Certiicates of Deposit (CD)

Case on hand or in safe deposit

c c c

Money market accounts Christmas club accounts

Savings, bonds, stocks or mutual funds

c c c

Savings/share accounts

Patient trust fund

IRA, KEOGH, 401K or Deferred

Compensation account(s)

c Trust or Annuity

c Land contract, mortgage or other

 

notes payable to household member

cReal estate (including place you live)

c c c

Life estate/life lease

 

c Burial plot(s), casket, etc.

 

c Tools, equipment, livestock or crops

Life insurance

 

c Other Assets ___________________

c Health Savings Account

Burial trust/funeral contract(s)

 

 

 

 

 

 

 

 

Type(s)

 

 

Name and address

 

Account/policy

Owner(s)

 

 

Balance

 

of asset(s)

 

of Asset(s)

 

amount of value

(bank, insurance company, etc.)

 

number, etc.

 

 

 

 

 

 

 

 

 

 

 

The Michigan Department of Health and Human Services (MDHHS) does not

AUTHORITY:

42 CFR Part 435.

discriminate against any individual or group because of race, religion, age,

COMPLETION:

Voluntary.

national origin, color, height, weight, marital status, genetic information, sex,

PENALTY:

No Healthcare Coverage.

sexual orientation, gender identity or expression, political beliefs or disability.

*Optional if the community spouse is not requesting assistance.

DHS-4574-B (Rev. 5-16) Previous edition obsolete.

1

ASSETS

2. Does anyone in your household have any vehicles?

c Yes

4Check all types of assets your household has and complete the table

c No

c Car

c Truck c Boat

Owner(s)

(As shown on vehicle title

or registration)

c Camper/trailer

c Motorcycle

c RV

c Other Vehicle

Year

Make/Model

Amount Owed

 

 

 

3. Has anyone in your household:

•sold or given away property, land, vehicles, stocks, bonds, savings, cash, checking, income, etc., closed any accounts or removed or added a name on any asset within the last 60 months?

•iled a pending lawsuit which may bring money, property, etc.?

•received a one-time cash payment (such as worker’s compensation, lottery winnings, insurance settlement, lawsuit award, etc.) within the last 60 months?

•or has anyone acting for any household member, ever put any money, lawsuit settlement, income or assets in a trust, annuity or similar legal device?

c Yes 4Who:

cNo

cYes 4Who:

cNo

cYes 4Who:

cNo

cYes 4Who:

cNo

AFFIDAVIT

I swear or afirm that all the information that I have written on this form or told to a specialist is true. I understand that I can be prosecuted for perjury if I have intentionally given false information. I also know that I may be asked to show proof of any information I have given. I also know that if I have intentionally left out any information or if I have given false information, which causes me to receive assistance I am not entitled to or more assistance than I am entitled to, I can be prosecuted for fraud.

Estate Recovery. I understand that upon my death the Michigan Department of Health and Human Services (MDHHS) has the legal right to seek recovery from my estate for services paid by Healthcare Coverage. This means that some or all of my estate may be recovered. MDHHS will not seek to recover against the estate while there is a legal surviving spouse or a legal surviving child who is under the age of 21, blind, or disabled. An estate consists of real and personal property. If you have received an asset disregard due to a long-term care partnership policy, Estate Recovery applies to all assets whether they are subject to probate administration or not. Estate recovery only applies to certain Healthcare Coverage recipients who received Healthcare Coverage services after the effective date of the estate recovery statute. MDHHS may agree not to pursue recovery if an undue hardship exists. An application must be submitted to determine if the applicant qualiies for an undue hardship waiver. Undue hardship waivers are temporary. For further information regarding Estate Recovery, call 800-642-3195.

Signature (Patient or Representative)

Date (Month, Day, Year)

Two Witnesses Only If Signed by Mark X

Signature of First Witness

Signature of Second Witness

NOTE: If you signed this application on behalf of someone else, complete the information below.

Name (First, Middle, Last)

Phone Number

Relationship to Patient

Street Address

City

State

Zip Code

DHS-4574-B (Rev. 5-16) Previous edition obsolete.

2

How to Edit Dhs 4574 B Form Online for Free

dhs 4574 b spouse form can be completed online without any problem. Just use FormsPal PDF tool to complete the job fast. The tool is continually updated by our staff, getting useful functions and growing to be even more convenient. Getting underway is simple! Everything you need to do is follow the following basic steps down below:

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Step 2: As you access the file editor, you will find the form ready to be filled out. In addition to filling in various fields, you may as well perform other actions with the file, specifically adding your own text, changing the original textual content, inserting graphics, affixing your signature to the form, and more.

This PDF will need specific information to be entered, so you should definitely take whatever time to fill in exactly what is required:

1. When filling in the dhs 4574 b spouse form, make certain to include all needed blank fields in their relevant section. This will help expedite the work, allowing your information to be processed quickly and correctly.

Stage # 1 of submitting michigan declaration patient

2. Soon after the previous section is filled out, go to enter the relevant information in these: c Life estatelife lease c Life, notes payable to household member, c Burial plots casket etc c Other, c Tools equipment livestock or, Owners of assets, Types, of Assets, Balance, amount of value, Name and address, bank insurance company etc, Accountpolicy number etc, AUTHORITY COMPLETION PENALTY, CFR Part Voluntary No Healthcare, and Optional if the community spouse.

Filling out part 2 in michigan declaration patient

3. Completing c Car, c Truck, c Boat, c Campertrailer, c Motorcycle, c RV, c Other Vehicle, Owners, As shown on vehicle title, or registration, Year, MakeModel, Amount Owed, Has anyone in your household, and sold or given away property land is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Year, Amount Owed, and As shown on vehicle title of michigan declaration patient

4. The next section arrives with these fields to consider: Estate Recovery I understand that, Signature Patient or Representative, Date Month Day Year, Two Witnesses Only If Signed by, Signature of First Witness, Signature of Second Witness, If you signed this application on, NOTE Name First Middle Last, Phone Number, Relationship to Patient, Street Address, City, State, Zip Code, and DHSB Rev Previous edition obsolete.

michigan declaration patient writing process shown (part 4)

Concerning State and Zip Code, be sure that you double-check them in this current part. The two of these are viewed as the key ones in the page.

Step 3: Go through the information you have typed into the blank fields and press the "Done" button. After creating a7-day free trial account with us, it will be possible to download dhs 4574 b spouse form or send it via email at once. The PDF will also be at your disposal through your personal cabinet with your every single edit. FormsPal guarantees risk-free document editing without personal data record-keeping or any sort of sharing. Be assured that your information is safe with us!

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