Ldss 4411 Form – Fill Out and Use This PDF

LDSS-4411 (12/99)

Page 1

RECERTIFICATION FOR MEDICAL ASSISTANCE (Chronic Care)

NEW YORK STATE

OFFICE OF TEMPORARY AND DISABILITY ASSISTANCE

DIRECTIONS

LOCAL DISTRICT NAME AND ADDRESS

RECERTIFICATION REFLECTS

1. Please Print Clearly.

฀ NO CHANGE

Do Not Write in the Shaded Areas.

฀ CHANGE

2. Fill out the form completely and accurately.

3. Sign the Form on the Back Page.

฀ OUTSTANDING DOCUMENTATION NEEDS

4. Return this recertification to the address listed.

CENTER/

INTERVIEW DATE

UNIT ID

WORKER ID

CASE

CASE NUMBER

DISTRICT

MA ELIGIBILITY DATES

OFFICE

TYPE

2

0

FROM

TO

CASE NAME

NAME OF INDIVIDUAL INTERVIEWED

CATEGORIES

Mo.

Day

Yr.

Mo.

Day

Yr.

RECIPIENT’S INFORMATION

DATE OF BIRTH

FIRST NAME

M.I.

LAST NAME

Mo

Day

Yr.

SEX

SOCIAL SECURITY NUMBER

LIST MAIDEN/OTHER NAMES RECIPIENT HAS BEEN KNOWN BY

ONC

฀ MALE

฀ FEMALE

NAME AND ADDRESS OF RECIPIENT’S FACILITY

RECIPIENT’S SPOUSE’S INFORMATION

DATE OF BIRTH

SPOUSE’S FIRST NAME

M.I.

SPOUSE’S LAST NAME

Mo

Day

Yr.

IF SPOUSE IS DECEASED

IS SPOUSE APPLYING/RECERTIFYING/RECEIVING?

SPOUSE’S SOCIAL SECURITY NUMBER

Ｙ HERE ฀

฀ YES ฀ NO

SPOUSE’S ADDRESS

SPOUSE’S PHONE NUMBER

Area Code

(

)

LIST ANY OTHER/MAIDEN NAMES BY WHICH YOUR SPOUSE HAS BEEN KNOWN.

ONC

LIST ANY DEPENDENT FAMILY MEMBER WHO IS LIVING WITH YOUR SPOUSE.

FAMILY MEMBER’S

FAMILY MEMBER’S

SOCIAL SECURITY NUMBER

DATE OF BIRTH

Mo

Day

Yr.

LIST ANY FAMILY MEMBER’S RELATIONSHIP TO YOU OR YOUR SPOUSE.

NAME AND ADDRESS OF PERSON COMPLETING THIS FORM (If OTHER THAN Recipient or Recipient’s Spouse)

PERSON’S PHONE NUMBER

Area Code

( )

LDSS-4411 (12/99)

Page 2

RESOURCES

DO NOT WRITE IN SHADED AREA

LIST ANY RESOURCES THAT THE RECIPIENT MAY HAVE:

YES

NO

$

VALUE

ACCOUNT NUMBER

LOCATION

Personal Incidental Account (PIA)

Savings Account (Checking/Savings/

Certificate of Deposit in Bank,

Credit Union)

Expect Lawsuit Settlement, Inheritance

Trust Fund

Life Insurance

Annuity

Stocks, Bonds, Savings Bonds

Real Estate (Including Vacation Property

and Homestead)

Income-Producing Property

Non-Income-Producing Property

Own Home

Mutual Fund

IRA, KEOGH, 401-K, Deferred Comp.

Other Pension or Retirement Account

Burial Fund, Burial Trust, Burial Space

(Cemetery Plot), Funeral Agreement

Other Resources (Please Specify)

Motor Vehicle

Value

Year

Make

Model

HAVE YOU OR YOUR SPOUSE SOLD, GIVEN AWAY, OR TRANSFERRED ANY CASH, INCOME, REAL ESTATE, OR OTHER ASSET

WITHIN THE PAST 36 MONTHS (60 MONTHS FOR TRUSTS)?

YES

NO

ASSET

VALUE

WHO DID IT GO TO?

$

$

$

LDSS-4411 (12/99)

Page 3

INCOME

RECIPIENT’S INCOME

SPOUSE’S INCOME

FAMILY MEMBERS INCOME

LIST ANY INCOME THAT THE RECIPIENT, RECIPIENT’S SPOUSE, OR DEPENDENT FAMILY

YES

NO

AMOUNT

YES

NO

AMOUNT

YES

NO

AMOUNT

MEMBER, MAY HAVE:

Social Security/Railroad Retirement

Pension

Veteran’s Pension

IRA, KEOGH, 401-K, Deferred Compensation

Alimony/Spousal Payment

Mortgage/Rental Income

Annuity

Interest from Bank Accounts, Mutual Funds, Stocks, Credit Unit

Dividends from Stocks, Bonds, Mutual Funds

Other Income such as Disability Benefits, SSI, Employment, etc. (Please Specify)

Do you expect to receive income from a trust, Lawsuit Settlement, Inheritance, etc.?

HEALTH INSURANCE

DO NOT WRITE IN SHADED AREA

Does the Recipient Have Medicare (Red, White and Blue Card).

฀Yes

฀No

If Yes, Part A ฀ Part B ฀

Does the Recipient’s Spouse ฀ or Dependent Family Member ฀ have Medicare?

฀Yes

฀No

If Yes, Part A ฀ Part B ฀

Are you, Your Spouse or a Dependent Family Member covered under any Health Insurance Plan, such as Plans provided by Employer, Unions,

Retirement System; Coverage under Support Order, Private Insurance Plans or VA (Aid and Attendance)?

฀Yes

฀No

Name of Covered Person(s)

Who Pays the Premium

Name of Insurance Company

Policy Number

Who Does the Policy Cover?

Effective Date of Policy

Amount of Premium and how often paid?

HOUSING EXPENSES

Does Your Spouse have a Housing Expense? If

MONTHLY RENT AMOUNT

MONTHLY MORTGAGE AMOUNT

MONTHLY TAX AMOUNT

MONTHLY HEAT BILL

Yes, Fill in the Requested Information.

฀Yes

฀No

$

$

$

$

RACE/ETHNIC AFFILIATION FOR APPLICANT ONLY

(Completion is optional. However, if not completed, the interviewer may have to record it by observation. This information is being collected only

to be sure that everyone receives assistance/care on a fair basis. This information will not affect your eligibility.) I am: (Check Only One)

B ฀Black not of Hispanic origin

W ฀White not of Hispanic origin

I ฀American Indian or Alaskan Native

H ฀Hispanic

A ฀Asian or Pacific Islander

LDSS-4411 (12/99)

Page 4

NON-DISCRIMINATION NOTICE – This application will be considered without regard to race, color, sex, handicaps, religious creed, national creed, national origin or political beliefs.

SOCIAL SECURITY NUMBER – A person making application for Medical Assistance (MA) shall disclose the Social Security Number of any person for whom Medical Assistance is requested, except when the individual is an undocumented alien seeking MA-only for the treatment of an emergency medical condition. Such disclosure is mandatory for Medical Assistance under the authority of Sections 351.2 and 360-1.2 of 18NYCRR and 42 USC 1320b-7. Social Security Numbers are used to provide proper identification of applicants for and recipients of Medical Assistance and to verify income, eligibility and benefits amounts. We will also be using your Social Security Number to match with IRS unearned income data and with the New York State Department of Labor for earned income data.

CONSENT – I understand that by signing this application/certification form I agree to any investigation made by the Department of Social Services to verify or confirm the information I have given or any other investigation made by them in connection with my request for Medical Assistance. If additional information is requested, I will provide it.

CHANGES – I agree to inform the agency promptly of any change in my needs, income, property, living arrangements or address to the best of my knowledge or belief.

ASSIGNMENT OF INSURANCE AND OTHER BENEFITS – I will file any claims for health or accident insurance benefits or any other resources to which I am entitled, and do hereby assign any such resources to the Social Services official to whom this application is made. In addition, I will assist in making any required assignment of benefits or resources to the Social Services official to whom this application is made.

DIRECT PAYMENT – I authorize the payment to me or members of my household for health or accident insurance benefits be made directly to the appropriate Social Services official for medical and other health services furnished while we are eligible for Medical Assistance.

MEDICARE – I authorize payments under “Medicare” (Part B of Title XVIII, Supplementary Medical Insurance Program) to be made directly to physicians and medical suppliers on any future unpaid bills for medical and other health services furnished to me while I am eligible for Medical Assistance.

PENALTIES – I understand that my application may be investigated, and I agree to cooperate in such an investigation. Federal and State Law provide for penalties of fine, imprisonment of both if you do not tell the truth when you apply for Medical Assistance benefits or at any time when you are questioned about your eligibility, or cause someone else not to tell the truth regarding your application or your continuing eligibility. Penalties also apply if you conceal or fail to disclose facts regarding your initial and continuing eligibility for Medical Assistance or if you conceal or fail to disclose facts that would affect the right of someone for whom you have applied to obtain or continue to receive Medical Assistance benefits; and such benefits must be used for that other person and not for yourself.

Federal and State Law provide that any transfer of an asset for less than fair market value made by an individual or his/her spouse within or after the thirty-six months (sixty months for transfers to trusts) immediately preceding the first day of the month in which the individual becomes institutionalized, or the date of application for Medical Assistance as an institutionalized person, if later, may render the individual ineligible for nursing facility services.

CERTIFICATION – In signing this application, I swear and affirm that the information I have given or will give to the Department of Social Services as a basis for Medical Assistance is correct. I also assign to the Department of Social Services any rights I have to pursue support from persons having legal responsibility for my support and to pursue other third-party resources. I understand that I may be required, as a condition of eligibility for Medical Assistance, to assign to the Department of Social Services the proceeds of the sale of my excess resources. I understand that upon receipt of Medical Assistance, a lien may be filed and a recovery may be made against my real property under certain circumstances if I am in a medical institution and not expected to return home. I understand that Medical Assistance paid on my behalf may be recovered from persons who had legal responsibility for my support at the time medical services were obtained.

RECIPIENT’S SIGNATURE

DATE SIGNED

SPOUSE’S SIGNATURE

DATE SIGNED

X		X
REPRESENTATIVE’S SIGNATURE	DATE SIGNED
X
WORKER’S SIGNATURE	DATE SIGNED	SUPERVISOR’S SIGNATURE	DATE SIGNED
X		X