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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M. Do you or your spouse have a safety deposit box?

Yes (

)

No (

)

Location:

Owner(s):

List Contents:

N.Do you or your spouse own a home?

Yes (

)

No (

)

Location:

Owner(s):

Who lives in the home? _____________________

Amount owed on home? $_______________

O.Do you or your spouse own real property (land, city lots, etc.)?

Yes (

) No ( )

Is this property rented?

Owner(s):

Value:

County Located:

Yes (

) No ( )

$

P. Do you or your spouse own any buildings or property rights (including mineral or

timber rights)? Yes

(

) No ( )

Where?

(County & State)

Owner(s):

Value:

Description:

$

Q.Do you or your spouse retain a life estate in any property?

Yes ( )

No ( )

Owner(s) of property

County

Property

Legal Description:

Location:

Value:

$

R. Do you or your spouse have real property held in trust by the U.S. Government (ie:

lease land)? Yes (

) No ( )

Tribe of Enrollment:

Enrollment

Yearly Lease

IIM Account No.:

Number:

Income:

County:

$

S. Do you or your spouse own business equipment, machinery, livestock, antiques, or

collections other than household furnishings?

Yes

(

)

No

(

)

Please List

Value:

___________________________________________________________

$

___________________________________________________________

$

___________________________________________________________

$

___________________________________________________________

$

___________________________________________________________

$

___________________________________________________________

$

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T. Have you or your spouse sold property on a contract for deed? Yes ( ) No ( )

U.Do you or your spouse have ownership in licensed or unlicensed cars, trucks, motorcycles, boats, recreational vehicles (camper, snowmobile), or any other vehicle?

Yes ( ) No ( ) If yes, complete below.

Owner’s First and Last Name:				Co-owner’s First and Last Name:			Amount Owed:
Year, Type, Make and Model of				Primary Use of Vehicle:			Value:
Vehicle:
							$
Owner’s First and Last Name:				Co-owner’s First and Last Name:			Amount Owed:
Year, Type, Make and Model of				Primary Use of Vehicle:			Value:
Vehicle:
							$
V.Do you or your spouse have life insurance policies? Yes ( )						No (	)
If yes, list all policies:
Policy No.	Name of Company		Address		Policy Owner	Face Value		Cash Value

W. Do you or your spouse have any financial arrangements such as contracts, insurance,

or accounts designated for burial? Yes (				) No (		) If yes, list below.
			Applicant					Spouse
Where?______________________________					Where?______________________________
____________________________________					____________________________________
Face Value ___________________________					Face Value___________________________
Does the interest stay in this account?					Does the interest stay in this account?
Yes ( )	No	(	) If no, is the interest paid		Yes (	) No	(	) If no, is the interest paid
to you?	Yes	(	) No ( )		to you?	Yes	(	) No ( )

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D.In the last 60 months were any of your or your spouse’s funds or property placed in

trust for you, your spouse, or anyone else?

Yes ( ) No ( )

If yes, complete below.

1.Date Established:

Value:

Name of Trustee:

Address of Trustee

2.Date Established:

Value:

Name of Trustee:

Address of Trustee

E.In the last 60 months has any payment from a trust (either income or principal)

become unavailable to you or your spouse? Yes

(

)

No (

)

If yes, complete the following:

Date payment stopped or ceased to be available: Month

Day

Year

Name of Trustee:

Address of Trustee:

F. Is any of your income paid directly into a trust?

Yes

(

) No (

)

If yes, complete below:

Date trust was established. Month

Day

Year

Name of Trustee:

Address of Trustee:

11.Health Insurance/Long Term Care Insurance

A.Do you or your spouse have any health insurance coverage? Yes ( ) No ( )

If yes, complete below for each person insured.

	Insurance Company Name & Add.			Policy Number	Type of Coverage	Premium Amount
	____________________________				Inpatient	Paid:
				__________	Hospital	$ _____________
					Outpatient	Monthly
	Name of Insured			Group Number	Dental	Quarterly
					Cancer	Semi-Annually
	____________________________
				___________	Medicare	Annually
	Policy Holder Name			Policy Began	Supplement	Employer Name
	____________________________
				___/___/___	Other (i.e.	(if group insurance)
					prescriptions,
						_____________
					Workman’s Comp.)

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	Insurance Company Name & Add.	Policy Number	Type of Coverage	Premium Amount
	____________________________		Inpatient	Paid:
	____________________________	__________	Hospital	$ _____________
			Outpatient	Monthly
	Name of Insured	Group Number	Dental	Quarterly
			Cancer	Semi-Annually
	____________________________	___________	Medicare	Annually
	Policy Holder Name	Policy Began	Supplement	Employer Name
	____________________________	___/___/___	Other (i.e.	(if group insurance)
			prescriptions,
				_____________
			Workman’s Comp.)
	B. Do you or your spouse have any Long Term Care Insurance? Yes (			) No ( )

If yes, complete below for each person insured.

Insurance Company Name & Add.	Policy #	Person Insured	Premium Amount
____________________________	__________		Paid:
____________________________	__________		$______________
____________________________	Partnership		Monthly
			Quarterly
	Plan?
____________________________			Semi-Annually
	Yes ( ) No ( )		Annually
Insurance Company Name & Add.	Policy #	Person Insured	Premium Amount
____________________________	__________		Paid:
____________________________	__________		$______________
____________________________	Partnership		Monthly
			Quarterly
	Plan?
____________________________			Semi-Annually
	Yes ( ) No ( )		Annually

12.Income (List all income and benefits that you or your spouse receive from any source.)

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13.Would you like to Register to Vote?

Any citizen in the State of South Dakota who meets the voter registration requirements and applies for public assistance must be provided the opportunity to register to vote.

A.If you are not registered to vote where you live now, would you like to apply to vote? Yes ( ) No ( ) If you checked yes, the Department of Social Services will send you a voter registration form. Return the completed registration card to the County Auditor in your county of residence or to your local Department of Social Services office, Department of Human Services office, WIC office or military recruitment office. The deadline for registration is 15 days before any election.

If you did not check either box, you will be considered to have decided not to register to vote at this time.

Please note that the information and office to which application was made will remain confidential and be used for voter registration purposes. Applying to register or refusing to register to vote will not affect the amount of assistance or services that you may receive from the Department of Social Services. If you would like help filling out the voter registration form, we will help you. The decision whether to seek or accept help is yours. You may fill out the application in private.

If you believe that someone has interfered with your right to register to vote, your right to privacy in deciding whether to register or in applying to register to vote, or your right to choose your own political party or other political preference, you may file a complaint with the:

South Dakota Secretary of State, 500 E Capitol, Pierre SD 57501, (605) 773-3537

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ASSIGNMENT OF MEDICAL SUPPORT, INSURANCE PROCEEDS

An application for and acceptance of medical assistance paid from the Department of Social Services shall operate as an assignment and subrogation of any rights to medical support, insurance proceeds, or both that the applicant or recipient may have. Any rights or amounts so assigned or subrogated shall be applied against the cost of the applicant’s or recipient’s care.

DISCLOSURE OF ANNUITIES AND STATE TO BE NAMED AS REMAINDER BENEFICIARY

Public Law No. 109-171 Deficit Reduction Act of 2005 Section 6012 requires individuals applying for long- term care medical assistance and an individual whose eligibility is being reviewed for purposes of determining whether the individual continues to be eligible for long-term care assistance to disclose the description of any interest the individual or the individual’s spouse has in an annuity or similar financial instrument. Failure to disclose this information results in ineligibility for assistance. In addition, a recipient of long term care assistance must name the department as a preferred remainder beneficiary of any interest the individual or individual’s spouse has in an annuity or similar financial instrument purchased and owned after February 7, 2006. Note: The annuity will also be considered a resource.

ESTATE RECOVERY AND MEDICAL ASSISTANCE LIENS

Under Federal and State law, the Department of Social Services is authorized to make recovery from the estates of deceased medical assistance recipients who were permanently institutionalized or who were at least 55 years of age and for whom the Department made a payment for nursing facility services, intermediate care facility services for the mentally retarded, other medical institutional services, home and community based services, hospital services, and prescription drug services. The Department of Social Services is authorized to recover the debt of a medical assistance recipient from the estate of a surviving spouse. If a surviving spouse wishes to limit the amount of the surviving spouse’s estate that will be liable for recovery for the amount of medical assistance paid on behalf of the recipient, the surviving spouse must file a petition within six months of the death of the medical assistance recipient. The petition will determine the amount of the surviving spouse’s estate from which recovery may be claimed for Medicaid expended on behalf of the recipient. The petition must be filed on the Department’s form.

Under Federal and State law, the Department of Social Services may impose a medical assistance lien against real property owned by a recipient who has received a benefit from the Department of Social Services for the services of a nursing facility, an intermediate care facility for the mentally retarded, or other medical institution. The Department of Social Services will issue a separate notice when the Department decides to impose a lien. The notice will describe the amount of the lien and the real property to which the lien is to attach.

Under State law, the Department of Social Services is authorized to recover any funds of the resident kept or maintained by the nursing home or other facility if the resident was receiving medical assistance from the Department at the time of death.

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PRIVACY ACT STATEMENT

Federal and State Law and Regulations limit the use and disclosure of confidential information concerning applicants and recipients of economic and medical assistance programs to purposes directly related to the administration of those programs. When you apply for assistance from the Department of Social Services, you

will be asked to provide your Social Security Number on the application form. Title 42 of the Code of Federal Regulations Part 435.910(a), requires the furnishing of Social Security Numbers as a condition of eligibility for Medicaid. The Department uses your number in its computer processing for eligibility determination, welfare fraud investigations and audits. Social Security Numbers are also used to verify income information through agencies such as Internal Revenue Service, Department of Labor, and Social Security Administration, etc., to prevent a person or family from receiving duplicate benefits under any program, to make mass changes in benefits easier to implement and to determine the accuracy and reliability of information given to the department by applicants for and recipients of assistance.

VERIFICATIONS

Information you give to answer the questions on this form, and information obtained by the department to verify your answers will be used to determine your eligibility and level of benefits. Your benefits may change from month to month, or be stopped, based on this information.

Federal and state officials will verify information given on this form to determine if it is correct. A department representative may contact you or may contact other people in order to verify your eligibility for assistance. Information given will also be verified by computer cross-matching with other agencies and private sectors. When state and federal personnel verify the information on this application, if what is reported is found to be incorrect your Medical case may be denied or terminated and you may be subject to criminal prosecution for knowingly providing false information.

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AUTHORIZATION TO FURNISH AND RELEASE INFORMATION

I hereby authorize any person, agency or institution to supply information requested by the Department of Social Services concerning me or my family, and to allow inspection and reproduction of records in his or their possession pertaining to me or my family by any duly authorized representative of the Department. I further authorize the Department to release such information to providers or cooperating State or Federal Agencies.

This authorization is given only in connection with its use by the Department in the administration of its programs and for no other purpose. It shall continue in effect until such time as I state in writing that it is no longer valid.

I herewith release any person, agency or institution from any and all liability to me or my family for supplying such information.

CIVIL RIGHTS GUARANTEE

The provisions of the Civil Rights Act of 1964, as amended, also apply to your case and department representatives shall not, on the grounds of race, color, creed, religion, sex, disability, ancestry, or national origin, exclude you from participation in, deny the benefits of, or otherwise subject you to discrimination under any program or activity administered by the department. Any person who feels that his civil rights have been violated may request a fair hearing. You may also file a complaint of discrimination by writing DSS Division of Legal Services, 700 Governors Drive, Pierre, SD 57501-2291 or by calling (605) 773-3305.

ACKNOWLEDGEMENT

I understand that any false statements which I may make and any failure on my part to report any change in circumstance which would affect my eligibility for payment from programs administered by the South Dakota Department of Social Services constitutes a crime and that I could be prosecuted under South Dakota criminal laws.

I agree to provide information upon request from the Department of Social Services concerning any asset or estate which may be subject to recovery, estate recovery, or medical assistance liens by the State of South Dakota.

SIGNATURES

Applicant should sign the application unless incapacitated or represented by a Legal (Court Appointed) Guardian. A representative, who can make health related decisions, may sign the application on behalf of the incapacitated or deceased applicant. The applicant’s mark should be witnessed by a person familiar with the applicant.

___________________________________________		_________________________________________
Signature of Applicant or Recipient	Date	Signature of Spouse	Date
___________________________________________		_________________________________________
Witness to Applicant’s mark	Date	Signature of	Date
		Legal Guardian or Power of Attorney
___________________________________________		_________________________________________
Name of	Date	Signature of	Date
Individual Assisting Applicant		Individual Assisting Applicant

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