Dss Ea 240 Form – Fill Out and Use This PDF

DSS-EA-240 05/12Recipient # ______________________________ Section _____2______

Application for Long Term Care or Related Medical Assistance

	Instructions to the Person Applying for Assistance						For Office Use Only
	Please read all questions carefully before filling out this form and						Case Number Assigned
	any attached supplements. This information will be used in
	determining your eligibility and need for assistance. All questions
	on the form must be completed. If you need help completing or
								ID# Assigned
	understanding this form, contact the Department of Social Service
	in the county where you live. The form and attachments, when
	completed and signed by the applicant or authorized representative
	and witnessed as indicated, should be returned to your local Social
							Date received in local
	Service Office. All information must be verified. Please attach
								office:
	copies of all verifications.
	This application is for: Long Term Care				Assisted Living
	Adult Foster Care				Other

Facility Name: ____________________________________________________________

1. Personal Information(Please Print)

A.Your Name: ______________________________________________________________

(First)(Middle)(Last)

B. Current Address:_______________________________________________________________

(Nursing Home, Hospital, etc.) (Street) (City) (Zip) (County) Home

Address: ______________________________________________________________

		(Street)		(City)		(Zip)			(County)
Home Telephone Number ( _____ )				_____–_____________________
C. Race (can check more than one)				D. Ethnicity	E.	Sex
(	)	White		Also check here		Male	(	)
(	)	American Indian		if Hispanic		Female	(	)
(	)	Black		( )
					F. Current Marital Status
(	)	Hawaiian
					(	) Married		(	) Divorced
(	)	Asian
					(	) Single		(	) Widowed
G.Birth Date				H. Social Security Number
_____		_____	______	________-______-_________
Month Day			Year

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K. How many months have you or someone else paid private rate for your continuous care in any facility? _______ months

L. Are you a United States citizen? Yes ( ) No ( )

If no, please provide proof of immigration status.

M. Are you a resident of South Dakota? Yes ( ) No ( )

Have you applied for or received assistance from South Dakota in the past? Yes ( ) No ( ) If yes, in what county? _______________________________________________________.

N.Medicare Claim Number	O. Civil Service Annuity #		P. Railroad Retirement #
Q.Veterans Benefit Number	R. Do you have Medicare
	Part A? Yes ( )	No ( )
	Part B? Yes ( )	No ( )
	Part D? Yes ( )	No ( )

Part D Plan: _________________________________

* Completion of social security numbers (SSN) is optional for persons not requesting assistance.

E. Social Security Number

F. Medicare Claim Number G.Civil Service Annuity No.

H.Railroad Retirement Number I. Are you or was your	J. Veterans Benefit Number
spouse a Veteran?
Yes ( ) No ( )

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6. Legal Guardian/Power of Attorney

Do you have a legal (court-appointed) guardian? Yes ( ) No ( )

Do you have a Power of Attorney? Yes ( ) No ( )

Name and address of this person ________________________________________________

___________________________________________________________________________

___________________________________________________________________________

Telephone number_______________________________________

Date of guardianship or Power of Attorney (Month & Year) __________________________

Please provide a copy of document unless previously provided.

7.Is Another Person Completing This Form?

If you are completing this form for another person give:

Your Full Name (Print) _______________________________________________________

Address ___________________________________________________________________

________________________________________________________________________

Telephone ( _______ )________________________________________________________

Your Title or Relationship to Applicant ( ) Family____________________________

( ) Social Worker ( ) Case Worker ( ) Other ____________________________

Name & address of applicant’s relative or friend who may be contacted for information:

________________________________________________________________________

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8.Name of Facility Social Worker

If you live in a facility, please provide the name of the Facility Social Worker:

________________________________________________________________

9.Resources/Assets Complete questions below for yourself and your spouse.

(Include all your resources/assets, and those owned by your spouse or owned jointly with anyone.)

(NOTE: YOU ARE REQUIRED TO VERIFY ALL OF THE FOLLOWING INFORMATION)

A.Cash on hand, savings at home, or money held by friends/relatives		Yes ( ) No ( )
Description:	Owner(s):		Value:
			$
B. Do you have money in a nursing home account? Yes ( ) No (		)
Current Balance:

C. Do you or your spouse have checking accounts, money market accounts, employee payroll debit card(s), or Direct Express (Federal Benefits) card(s)? Yes ( ) No ( )

NOTE: You are required to attach copies of your most recent bank statements.

D.Do you or your spouse have savings accounts? Yes ( ) No ( )

E. Do you or your spouse have health savings accounts established through a bank, credit union, insurance company or employer ? Yes ( ) No ( )

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