Form Dco 777 – Fill Out and Use This PDF

ARKANSAS DEPARTMENT OF HUMAN SERVICES LONG TERM CARE APPLICATION FOR ASSISTANCE

What services are you requesting?

Si necesita este formulario en Español, llame al 1-800-482-8988 y pida la versión en Español

If you need this material in a different format, such as large print contact your DHS county office.

1.	I am a resident of Arkansas: Yes	No	2. I am:	65 years of age or older	Blind	Disabled
3.	My full name is: ____________________________________________________				Race ______ Sex ______
	Last		First	Middle

4.My current address is: ___________________________________________________________________________

		Physical Address	City	State	Zip	County
	______________________________________________________________________________________________
	Mailing Address (P.O. Box)		City	State	Zip	County
	My former address was: ___________________________________________________________________________
		Mailing Address	City	State	Zip	County
	I have lived at my current address for: _________ years.
5.	My telephone number is: _________________________			6. I was born on: ______________________________
				Month	Day	Year
7.	_____________________	______________________		I was born in: ______________________________
	Social Security Number	Medicare Number		City or County
	_____________________	______________________		_____________________________
	Railroad Ret. Number	VA Claim Number		State or Country

Complete Questions 11 – 15 ONLY if you have a Spouse

11.My spouse’s name is: ______________________________________________________________________

Last

First

Middle

12.My spouse’s address is: ____________________________________________________________________

Street or Route No.

City

State

Zip

County

13.My spouse’s telephone number is: _______________ 14. My spouse was born on: ___________________

			Month	Day	Year
15. _____________________	______________________	___________________	_____________________
Spouse’s Soc. Sec. No	Spouse’s Medicare No.	Spouse’s Railroad Ret. No.	Spouse’s VA Claim No.

DCO-777 (R.01/12)

Page 1 of 4

16. I and my spouse have income from the following: (Check (√) Yes or No. If yes enter the amount and how often the income is received).

	MYSELF			MY SPOUSE
					HOW
SOURCE OF INCOME	YES NO AMOUNT HOW OFTEN	YES	NO	AMOUNT	OFTEN

Retirement Benefits

Social Security Benefits

SSI

Veteran’s Benefits

Railroad Retirement

Civil Service Benefits

Interest/Dividends

Insurance

Money From Trusts

Mineral Rights/Oil Leases

Rental

Cash Contributions

Unemployment Benefits

Worker’s Compensation

Employment/Work

Farming/Self Employment

Deposits by Others for Me

Other

Address of Home

Equity Value

I or my spouse formerly owned homes in:

City, County and State

City, County and State

Address of Property	Equity Value
Address of Property	Equity Value

I or my spouse formerly owned real property other than my home in:

City,

County and State

21. I or my spouse have sold/deeded/given away a home or other real property:

To Whom

22. I or my spouse retain life estate, dower, curtesy, inheritance or other interest in a home or other property

Location of Property (City, County, State)

Type of Interest

Value

DCO-777 (R.01/12)

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23.I or my spouse own personal property such as cars, trucks, tractors or farm machinery, trailers, boats, etc.: (If more than three, please list on a separate sheet)

Item (Make, Model, and Year)	Equity Value
Item (Make, Model, and Year)	Equity Value
Item (Make, Model, and Year)	Equity Value

24. I or my spouse own livestock (cattle, poultry, catfish, minnows, crickets, worms, etc.)

Yes	No	If yes, complete the following:
Type of Livestock and Number Owned		Value

25.I or my spouse have the following assets. (Check (√) Yes or No. If yes, enter the amount/value, location of the asset, and name of joint owner, if any.)

TYPE	YES	NO	AMT/VALUE	LOCATION OF ASSET	NAME OF JOINT
					OWNER
Cash
Checking Account
Savings Account
Other Savings (Certificates, etc.)
Promissory Notes
Stocks
Bonds
Patient Fund Account
Mortgage
Burial Plot/Crypt
Burial Funds/Insurance
Life Insurance
Trusts
Other

26. I or my spouse have additional income and/or property (real or personal) that I was unable to list under items 16 through 23.

Yes

No

If yes, record your answer(s) on a separate sheet.

27.I or my spouse have other resources (real or personal property) that are being held for me by another individual.

Yes No If yes, complete the following:

	Type of Resource	Location of Resource		Amt/Value
	Type of Resource	Location of Resource		Amt/Value
28. I or my spouse have hospital/medical insurance coverage. Yes			No	If yes, complete the following:
	Name and Address of Insurance Company			Policy No.

•I understand that I must help establish my eligibility by providing as much of the requested information as I can.

•I authorize the Department of Human Services to make any investigation concerning me and/or my spouse necessary to establish my eligibility for assistance.

•I understand that no person may be denied long term care assistance or other Medicaid assistance on the grounds of race, color, sex, national origin or disability.

•I understand that I may request a hearing before the state agency representative if a decision is not reached on my case within the appropriate time limit or if I disagree with the decision reached.

•I agree to notify the Department of Human Services within 10 days if I or my spouse receive additional income, acquire or dispose of property or if any other changes occur in my circumstances.

•I authorize the Department of Human Services to examine all records of mine, or records of those receiving or having received Medicaid benefits through me, for the purpose of investigating whether or not any person may have committed Medicaid fraud or for use in any legal, administrative or judicial proceeding.

•I understand that I must provide my Social Security Number as a condition of my eligibility; and I understand that this number may be used by the Agency without my express permission in a computer match to obtain information relative to my eligibility for assistance from the Social Security Administration, Department of Workforce Services, Internal Revenue Services, or other agencies.

•ASSIGNMENT OF MEDICAL SUPPORT. I authorize any holder of medical or other information about me to release information needed for a Medicaid claim to DHS. I further authorize release of any information to other parties who may be liable for my medical expenses. As an eligibility condition I automatically assign my right to any settlement, judgement, or award which may be obtained against any third party to DHS to the full extent of any amount which is paid by DHS on my behalf. I authorize and request that funds, settlement or other payments made by or on behalf of third parties, including tortfeasors or insurers arising out of a Medicaid claim, be paid directly to DHS. My application for Medicaid benefits shall in itself constitute an assignment by operation of law and shall be considered a statutory lien of any settlement, judgement, or award received by me from a third party. A third party is any person, entity, institution, organization or other source which may be liable for injury, disease, disability or death sustained by me or others named herein, including estates of said individuals. I also assign all rights in any settlement made by me or on my behalf arising out of any claim to the extent of medical expenses paid by DHS, whether or not a portion of such settlement is designated for medical expenses. Any such funds received by me shall be paid to DHS. A copy of this authorization may be used in place of the original.

•I understand the requirement to disclose, in my application for Long Term Care services, information regarding any interest that I or my community spouse may have in an annuity.

•I understand the requirement to name the state as a remainder beneficiary in which I or my spouse is the annuitant.

•If you have questions or problems regarding your application or care, please call your State Long Term Care Ombudsman at 501-682-8952.

•IMPORTANT ESTATE RECOVERY NOTICE:

If you receive Medicaid in a nursing facility, ICF/MR facility, or under a home and community based waiver program, the total amount of the Medicaid benefits paid on your behalf will be a debt to DHS and may be recovered from your estate or from the grantee of a beneficiary deed after your death. Your estate is the property you own at the time of your death. DHS will not make a claim against your estate while you are living. DHS will not make a claim against your estate after your death if your spouse is still living, or if you have dependent children under age 21 or blind or children with disabilities. DHS will collect the debt, if any, by filing a claim in your estate. Collection may not be made if it is not cost effective to DHS or if your heirs apply for a hardship waiver after your death. A hardship may exist if the estate property is the only source of income for your heirs, if that income is limited, or if there are other compelling circumstances.

CERTIFICATION: I HAVE READ THE ABOVE STATEMENTS AND I AGREE TO THEIR PROVISIONS.

•FOR LONG TERM CARE FACILITY RECIPIENTS/APPLICANTS ONLY: After reviewing the alternatives to nursing facility placement available through the Department of Human Services, I understand that I am choosing to be served in a nursing facility.

•I understand that if I am admitted to a nursing facility based on conditional Medicaid approval and my Medicaid case is denied, I, or my family, will be responsible for any indebtedness while in the nursing facility.

•I understand that this form is signed subject to penalties for perjury, I understand that if I receive assistance to which I am not entitled as a result of withholding information or providing inaccurate information, such assistance will be subject to recovery by the Department of Human Services and I may be subject to prosecution for fraud and fined and/or imprisoned.