Maryland Form Dhr – Fill Out and Use This PDF

The Maryland Dhr form is an essential document for those seeking Long-Term Care/Waiver Medical Assistance through the Maryland Department of Health and Human Mental Hygiene and the Department of Human Resources. It serves as a comprehensive checklist and application that requests detailed information about an applicant’s financial situation, health insurance, and other pertinent data to determine eligibility for assistance. To start the application process and ensure you have all necessary documentation ready, click the button below.

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Maryland Form Dhr PDF Details

Applying for Long-Term Care or Waiver Medical Assistance in Maryland involves navigating through the intricacies of the application process, under the oversight of the Maryland Department of Human Resources and the Maryland Department of Health and Mental Hygiene. The process demands careful attention to detail, as applicants must provide a comprehensive set of documents to establish their eligibility. The required materials range from proof of income and assets over the past five years, to detailed information regarding property ownership, bank statements, and insurance policies. The aim is to ensure that all who apply receive a fair evaluation based on their financial situation and care needs, whether they or their spouse have disposed of any assets, or if there's a need for spousal monthly income protection. Additionally, the inclusion of federal tax returns, financial statements, and various personal documents underscores the thorough nature of this process. It's crucial for applicants to submit as many requested items as they can initially, though additional documents can be provided later if necessary. This approach underscores the importance of not delaying the application due to incomplete document availability. The detailed checklist serves not just as a requirement but as a guide to help applicants navigate through the process, offering clarity on what exactly needs to be submitted to support their application. Beyond just a formality, this application serves as a critical step for many in accessing necessary medical assistance for long-term care, highlighting its significance in the community's healthcare framework.

Question	Answer
Form Name	Maryland Form Dhr
Form Length	19 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	4 min 45 sec
Other names	maryland form dhr, 1130 rent and living arrangements verification form, dhr verification of rent and living arrangements form maryland, dhs verification of rent and living arrangements form

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MARYLAND DEPARTMENT of HUMAN RESOURCES

MARYLAND DEPARTMENT of HEALTH and MENTAL HYGIENE

LONG-TERM CARE/WAIVER MEDICAL ASSISTANCE APPLICATION

Check List of Items Needed for Your Long-Term Care / Waiver Application

(Please keep this page for your records)

SEND PROOF If you do not already receive Long-Term Care Medical Assistance, we need the items listed below to process your application. Please send as many items as you can with this application. Please send copies, do not send originals. In some cases, we may need to request additional documents not listed below. If so, we will give you time to supply the additional documents.

DO NOT WAIT TO APPLY

If you do not have copies of all the documents listed, send in all the copies you do have when you apply. It is important to apply as soon as possible. We will give you more time to send additional documents needed.

If you or your spouse sold, traded, gifted, or disposed of any property, motor vehicles, stocks, bonds, cash or other assets in the past 5 years you will have to provide the following:

□ Type of asset	□ Reason for transfer
□ Value of asset	□ Who received the asset
□ Amount received for the asset

If you want to find out if your spouse can keep some of your monthly income, please provide:

□ Spouse’s gross monthly income	□ Property tax bill
□ Condo fees	□ Rent
□ Mortgage	□ Electric bill
□ Lot Rent

The following items are needed from you and your spouse to determine if you are eligible for Long-Term Care Medical Assistance:

□Federal Tax Returns for the current year and the preceding four years (please include all forms and schedules). A Record of Account can be obtained from the IRS free of charge by calling 1-800-908-9946 if your Federal tax returns cannot be located.

□Bank and Financial statements on all accounts owned and co-owned:

□Current Month (month of application)

□Previous Month (month prior to application)

□The last five years of the anniversary month of the application

□Current statement of retirement accounts

□Current statement of IRA or Keogh Accounts

□Current statements of:

□Stocks

□Bonds

□Money Market Funds

□Mutual Funds, Treasury, or Other Notes

□Certificates

□Current gross monthly income from all sources including:

□VA Pensions

□Railroad Retirement

□Pensions

□Annuities

□Face and cash value of Life Insurance policies (current annual statement)

□Current statement for burial accounts

□Burial Plot Deeds

□Life Estate Deeds

□Promissory Notes

□Mortgage Notes and Mortgage Deeds

□Trusts (including appendices, schedules, annual accountings, and amendments for the past five years)

□Private Health Insurance Cards including Medicare (copy of both sides)

□Health Insurance premium amounts

□Power of Attorney or Legal Guardianship Documents (if any)

Please continue by completely answering every question on the attached application. If you need more space to complete the application, please attach additional sheets.

DHR/FIA 9709 (REVISED 7-1-11)

Blank Page

DHR/FIA 9709 (REVISED 7-1-11)

MARYLAND DEPARTMENT OF HUMAN RESOURCES MARYLAND

DEPARTMENT OF HEALTH AND MENTAL HYGIENE LONG-TERM

CARE/WAIVER MEDICAL ASSISTANCE APPLICATION

Date Signed Application

Received in Local Department

MUST BE DATE STAMPED

FOR WORKER

USE ONLY

This part is for our

staff. Please continue

to Section A.

LDSS Office	Programs Applied For or		Assistance Unit IDs
	Receiving		Client ID

Worker’s Name

Application Date

Program Medical Coverage Group		AU ID

SECTION A – BENEFIT SELECTION: Please tell us about which benefits you want and which benefits you already have.

I am applying for:

Long-Term Care Waiver

Do you need Medical Assistance for medical bills incurred in the past 3 months?

If yes, you will need to provide copies of the bills to your case manager.

YES NO

Tell us if you are currently receiving other assistance.

Icurrently receive:

Medical Assistance ID #

If you already receive Medical Assistance, please provide your ID number.

Cash Assistance

Food Stamps

Other, list:

If you receive any other benefits, please list all the benefits here.

SECTION B – APPLICANT INFORMATION: Please tell us about yourself.

Last Name

First Name

Middle Name

Suffix

Maiden Name or Other Name

(Jr., Sr., etc.)

Social Security Number:

Additional Social Security Number:

If you have a Social Security Number, enter it here.

If you have an additional Social Security Number, enter it here.

Date of Birth: (Month,Day,Year)

Gender:

Male

Female

DHR/FIA 9709 (REVISED 7-1-11)

Page 1 of 17

SECTION B – APPLICANT INFORMATION (continued)

Ethnicity

Optional

	Race	1 – American Indian/Alaskan Native
1 – Hispanic or Latino	Optional –	2 – Asian
	Please choose	3 – Black/African American
	all race codes	3 – Black/African American
2 – Not Hispanic or Latino	all race codes	4 – Native Hawaiian/Pacific Islander
2 – Not Hispanic or Latino	that apply to you.	4 – Native Hawaiian/Pacific Islander
	that apply to you.	5 – White
		5 – White

You do not have to give information about your race or ethnicity. If you do, it will help show how we obey the Federal Civil Rights Law. We will not use this information to decide if you are eligible. If you do not give us your race, it will not affect your application. The case manager will enter a race code for statistical purposes only. Title VI of the Civil Rights Act of 1964 allows us to ask for this information.

Are you a resident of Maryland?

YES

Marital Status

Single

Married

Divorced

Separated

Widowed

Are you receiving Medical Assistance (Medicaid) benefits from another state?

YES

NO	If yes, please list the state:

Are you a U.S. Citizen?

YES NO

If you answered NO, please complete SECTION C – IMMIGRATION STATUS, below.

What is your primary language?

Do you need an interpreter?

YES

If you are not registered to vote,

would you like to receive a voter registration form?

YES

Already registered to vote

SECTION C – IMMIGRATION STATUS (FOR NON-CITIZENS ONLY)

SEND PROOF Please send a photocopy of the front and back of your INS card.

What is your current INS

On what date did you receive

Are you a Sponsored

What is your Country of

Status?

your INS Status?

Immigrant?

Origin?

_/_

YES

When did you enter the U.S.?

What is your INS Number?

If you are a refugee, please list your Refugee Resettlement

Agency:

DHR/FIA 9709 (REVISED 7-1-11)

Page 2 of 17

SECTION D – CURRENT ADDRESS of HOME or INSTITUTION/LONG-TERM CARE

FACILITY: Please tell us about your Long-Term Care Facility, if you live in one.

If you live in a facility, what is the name of the facility?

On what date did you enter the facility?

_/ _/

What is your home address or the address of your facility?

Street

City	_ State		_ ZIP

Telephone #		Cellular Telephone #

Is this your mailing address? YES NO If you checked NO, please provide your mailing address information in Section V.

Do you (applicant/recipient) intend to return home?

YES

Do you (applicant/recipient) intend to return home within 6 months?

YES

SECTION E – PREVIOUS ADDRESSES: Please tell us where you have lived for the past

	five years.
Street		Did you or your spouse own
		this home?

City		State	_ ZIP

YES

Street			Did you or your spouse own
			this home?
City	State	_ ZIP	YES	NO

Street			Did you or your spouse own
			this home?
City	State	_ ZIP	YES	NO

Street			Did you or your spouse own
			this home?
City	State	_ ZIP	YES	NO

SECTION F – AUTHORIZED REPRESENTATIVE: Do you authorize someone to represent you in this application? If so, please tell us about your authorized representative.

First Name

Middle Name

Last Name

Suffix

(Jr., Sr., III, etc.)


Address		_
City	State	_ZIP

DHR/FIA 9709 (REVISED 7-1-11)			Page 3 of 17

SECTION F – AUTHORIZED REPRESENTATIVE (continued)

Home Telephone #

Cellular Telephone #		_
Work Telephone #			_

What is the authorized representative’s relationship to you?

If answer is spouse, please complete the next question:

Do you or your spouse own this home?

YES NO

If Authorized Representative is your spouse, please provide spouse’s Social Security Number:

SECTION G – SPOUSAL INFORMATION: Please tell us about your spouse. Leave this section blank if your spouse is listed as your Authorized Representative in Section F.

Last Name

First Name

Middle Name

Suffix

Maiden Name or Other Name

(Jr., Sr., etc.)

Spouse’s Social Security Number

Street

Do you or your spouse own

this home?

City

State

_ ZIP

YES NO

Telephone #

SECTION H – DISABILITY: Please tell us about your disability, if you have one.

Are you disabled?

If yes, when did the disability begin?

YES

What is your disability?

				Premium Amount
Do you receive Medicare Part A?	YES	NO	$
Do you receive Medicare Part B?	YES	NO	$
Do you receive Medicare Part B?	YES	NO	$		SEND PROOF	Please send
					verification of the premium
Do you receive Medicare Part C?	YES	NO	$		amounts you pay
Do you receive Medicare Part D?	YES	NO	$
If yes, please provide your Medicare Claim Number:

DHR/FIA 9709 (REVISED 7-1-11)

Page 4 of 17

SECTION I – VETERAN INFORMATION: If you are a veteran, a disabled widow(er), or a disabled child of a deceased veteran, fill in this section:

SEND PROOF Please send a photocopy of the front and back of your military service card.

Veteran’s Name

Relationship to Veteran

Veteran’s Status

Military Service Number

SECTION J – MEDICAL INSURANCE: If the applicant/recipient is insured, fill in this section: If you have more than one policy, place additional information in Section V.

SEND PROOF Please send a photocopy of the front and back of your insurance card(s) and verification of the premium amounts you pay.

Policy Number

Group Number

Policy Holder Name

Relationship to Policy Holder

Policy Effective Dates

From:

To:

Policy Holder Address

Street

City

State

ZIP

Telephone

Insurance Company

Insurance Company Name

Street

City

State

ZIP

Telephone

Union

Union Local

Union Name

Number

Street

City

State

ZIP

Telephone

DHR/FIA 9709 (REVISED 7-1-11)

Page 5 of 17

SECTION K – INCOME FROM WORKING: Please tell us about any income you or your spouse are currently receiving from working, including any sick leave payments.

SEND PROOF Please send copies of any proof of pay, such as a paystub. If you need additional space to complete this section, please use Section V or attach additional sheets.

Employer Name

Type of Job

Employer Address

City

State_

ZIP

Telephone #

Date Job

Gross Wages per Pay Period, including tips and

Began_

Ended_

commissions.

per

Hours per Pay Period

How often do you get

If the job has ended, what is your last expected pay date?

paid?

Weekly

Biweekly

Monthly

SECTION L – YOUR BENEFITS AND OTHER INCOME: Please tell us about any income or benefits that you are receiving, have applied for, or have been denied.

SEND PROOF Please send current copies of statements that verify the gross amount of income you receive.

TYPE OF BENEFIT	RECEIVING INCOME			AMOUNT	APPLICATION		APPLICATION DATE OR
OR INCOME	OR BENEFITS?			AMOUNT		STATUS	DENIAL DATE
OR INCOME	OR BENEFITS?					STATUS	DENIAL DATE
Social Security
Please write your claim number:	YES	NO	$			Applied for
	YES	NO	$			Denied
						Denied

Black Lung Benefits	YES	NO	$			Applied for
Black Lung Benefits	YES	NO	$			Denied
						Denied
SSI (Supplemental Security
Income)						Applied for
Please write your claim number:	YES	NO	$			Applied for
Please write your claim number:	YES	NO	$			Denied
						Denied

Veteran’s Pension/Benefits	YES	NO	$			Applied for
Veteran’s Pension/Benefits	YES	NO	$			Denied
						Denied
Pension or Retirement	YES	NO	$			Applied for
Pension or Retirement	YES	NO	$			Denied
						Denied
Civil Service Annuity	YES	NO	$			Applied for
Civil Service Annuity	YES	NO	$			Denied
						Denied
Railroad Retirement Benefits
Please write your claim number:	YES	NO	$			Applied for
	YES	NO	$			Denied
						Denied

Alimony	YES	NO	$			Applied for
Alimony	YES	NO	$			Denied
						Denied
DHR/FIA 9709 (REVISED 7-1-11)							Page 6 of 17

SECTION L – YOUR BENEFITS AND OTHER INCOME (continued)


TYPE OF BENEFIT	RECEIVING INCOME			AMOUNT	APPLICATION	APPLICATION DATE OR
OR INCOME	OR BENEFITS?			AMOUNT	STATUS	DENIAL DATE
OR INCOME	OR BENEFITS?				STATUS	DENIAL DATE
Worker’s Compensation	YES	NO	$		Applied for
Worker’s Compensation	YES	NO	$		Denied
					Denied
Disability/Sick Benefits	YES	NO	$		Applied for
Disability/Sick Benefits	YES	NO	$		Denied
					Denied
Union Benefits	YES	NO	$		Applied for
Union Benefits	YES	NO	$		Denied
					Denied
Unemployment Benefits	YES	NO	$		Applied for
Unemployment Benefits	YES	NO	$		Denied
					Denied
Lump Sum Cash Amounts	YES	NO	$		Applied for
Lump Sum Cash Amounts	YES	NO	$		Denied
					Denied
Interest/Dividends from Stocks,					Applied for
Bonds, Savings, or other	YES	NO	$		Applied for
Bonds, Savings, or other	YES	NO	$		Denied
investments					Denied
investments
Business Income	YES	NO	$		Applied for
Business Income	YES	NO	$		Denied
					Denied
Other (e.g., Rental Income, or					Applied for
Compensation from a Legal	YES	NO	$		Applied for
Compensation from a Legal	YES	NO	$		Denied
Settlement)					Denied
Settlement)
Other					Applied for
Please describe:	YES	NO	$		Applied for
Please describe:	YES	NO	$		Denied
					Denied

SECTION M – ASSETS: Please tell us about your assets as of the first day of this month. Check YES or NO for each ASSET TYPE. If you check YES, fill in the other boxes. List all assets owned by you or your spouse individually, jointly, or with other persons. If you have more than one asset of the same type, use the “Other” boxes at the bottom of the list.

SEND PROOF Please send copies of current statements that verify the value of the assets.

ASSET TYPE	CHECK ONE	OWNER	AMOUNT	ACCOUNT NUMBER	INSTITUTION NAME

Cash on Hand	YES		$
Cash on Hand	NO		$
	NO

Checking Account	YES		$
Checking Account	NO		$
	NO

Savings Account	YES		$
Savings Account	NO		$
	NO

Credit Union Account	YES		$
Credit Union Account	NO		$
	NO

Trust Fund	YES		$
Trust Fund	NO		$
	NO

IRA or Keogh	YES		$
Account	NO		$
Account	NO

Other Retirement	YES		$
Accounts	NO		$
Accounts	NO

Stocks and Bonds	YES		$
Stocks and Bonds	NO		$
	NO

DHR/FIA 9709 (REVISED 7-1-11)					Page 7 of 17

SECTION M – ASSETS (continued)

	ASSET TYPE	CHECK ONE	OWNER	AMOUNT	ACCOUNT NUMBER	INSTITUTION NAME

Treasury or Other		YES		$
Notes		NO		$
Notes		NO

Annuity		YES		$
Annuity		NO		$
		NO

Ownership in a		YES		$
Company		NO		$
Company		NO

Patient Fund Account		YES		$
Patient Fund Account		NO		$
		NO

Other		YES		$
		NO		$
		NO

Other		YES		$
		NO		$
		NO

Other		YES		$
		NO		$
		NO

Other		YES		$
		NO		$
		NO

SECTION N – OTHER ASSETS: Please tell us about any other assets you own and assets jointly owned with other individuals. This could include livestock, recreational vehicles, or any other property of value such as collections of antiques, coins, jewelry, or stamps.

SEND PROOF Please send copies of current statements or documents that establish the fair market value of the asset(s) as well as the amount owed.

ASSET TYPE

CURRENT FAIR MARKET VALUE

CURRENT AMOUNT OWED

OWNER(S)

SECTION O – POTENTIAL ASSET OR INCOME: Please tell us about any accident settlement, trust fund, inheritance, or any other money, property, real property, or assistance you expect to receive.

SEND PROOF Please send copies of current statements or documents that describe the nature, amount, and payment schedule of the asset.

Asset Type

Lawyer Name

DHR/FIA 9709 (REVISED 7-1-11)

Page 8 of 17

SECTION O – POTENTIAL ASSET OR INCOME (continued)

Explanation

	_
Anticipated
Date of Receipt	_

Lawyer Telephone #

SECTION P – REAL PROPERTY: Please tell us about any real property that you own in or out of the state of Maryland.

SEND PROOF Please send a copy of the deed to each property. Please also send copies of current documents that verify the equity value of each property.

Do you and/or your spouse own or have a legal interest in any other real property?

If yes, please answer the following questions:

YES

ADDRESS OF PROPERTY	TYPE OF OWNERSHIP	CURRENT FAIR MARKET VALUE	CURRENT AMOUNT OWED
ADDRESS OF PROPERTY	(CHECK ONE)	CURRENT FAIR MARKET VALUE	CURRENT AMOUNT OWED
	(CHECK ONE)

	Rental Property
	Vacation Property
	Time Share	$	$
	Vacant Land	$	$
	Vacant Land
	Other Property Rights
	Burial Plot

	Rental Property
	Vacation Property
	Time Share	$	$
	Vacant Land	$	$
	Vacant Land
	Other Property Rights
	Burial Plot

	Rental Property
	Vacation Property
	Time Share	$	$
	Vacant Land	$	$
	Vacant Land
	Other Property Rights
	Burial Plot

	Rental Property
	Vacation Property
	Time Share	$	$
	Vacant Land	$	$
	Vacant Land
	Other Property Rights
	Burial Plot

DHR/FIA 9709 (REVISED 7-1-11)

Page 9 of 17

SECTION Q – LIFE INSURANCE AND FUNERAL PLANS: Please tell us about any life insurance or pre-paid burial plans or funds that you own. Please list all policies and funds, no matter who pays for them.

SEND PROOF Please send a copy of the declaration page of each policy. Please also send copies of current statements to verify the cash value of each policy, if applicable.

ORIGINAL FACE			POLICY NUMBER		COMPANY,
ORIGINAL FACE			POLICY NUMBER		FUNERAL
VALUE OR VALUE OF	CASH VALUE	TYPE OF PLAN	OR ACCOUNT	POLICY OWNER	FUNERAL
VALUE OR VALUE OF	CASH VALUE	TYPE OF PLAN	OR ACCOUNT	POLICY OWNER	HOME, OR
PLAN			NUMBER		HOME, OR
PLAN			NUMBER		BANK NAME
					BANK NAME
$	$	Life Insurance
$	$	Burial Plan
		Burial Plan

$	$	Life Insurance
$	$	Burial Plan
		Burial Plan

$	$	Life Insurance
$	$	Burial Plan
		Burial Plan

SECTION R – TRANSFER OF ASSETS: Please tell us about any assets that you sold, traded, gifted, or disposed of in the past five years. This could include personal and real property, motor vehicles, stocks, bonds, cash, or other assets.

SEND PROOF Please send copies of current statements or documents that verify the date the asset was transferred, the value of the asset at the time of the transfer, and the amount you received for the transferred asset. If you need additional space to complete this section, please use Section V or attach additional sheets.

TRANSFER DATE

TYPE OF ASSET

VALUE OF THE ASSET AT

THE TIME OF THE

TRANSFER

WHO RECEIVED THE

ASSET AND THE REASON

FOR THE TRANSFER

AMOUNT RECEIVED

SECTION S – SPOUSAL BENEFITS AND OTHER INCOME: Please tell us about any income or benefits that your spouse is receiving, has applied for, or has been denied.

SEND PROOF Please send current copies of statements that verify the gross amount of income your spouse receives.

TYPE OF BENEFIT	RECEIVING			AMOUNT	APPLICATION	APPLICATION DATE OR
TYPE OF BENEFIT	BENEFITS?			AMOUNT	STATUS	DENIAL DATE
	BENEFITS?				STATUS	DENIAL DATE
Social Security
Please write your claim number:	YES	NO	$		Applied for
	YES	NO	$		Denied
					Denied

Black Lung Benefits	YES	NO	$		Applied for
					Denied


SSI (Supplemental Security Income
Please write your claim number:	YES	NO	$		Applied for
	YES	NO	$		Denied
					Denied

DHR/FIA 9709 (REVISED 7-1-11)						Page 10 of 17

SECTION S – SPOUSAL BENEFITS AND OTHER INCOME (continued)


TYPE OF BENEFIT	RECEIVING			AMOUNT	APPLICATION	APPLICATION DATE OR
TYPE OF BENEFIT	BENEFITS?			AMOUNT	STATUS	DENIAL DATE
						DENIAL DATE

Veteran’s Pension/Benefits	YES	NO	$		Applied for
Veteran’s Pension/Benefits	YES	NO	$		Denied
					Denied
Pension or Retirement	YES	NO	$		Applied for
Pension or Retirement	YES	NO	$		Denied
					Denied
Civil Service Annuity	YES	NO	$		Applied for
Civil Service Annuity	YES	NO	$		Denied
					Denied
Railroad Retirement Benefits
Please write your claim number:	YES	NO	$		Applied for
	YES	NO	$		Denied
					Denied

Alimony	YES	NO	$		Applied for
Alimony	YES	NO	$		Denied
					Denied
Worker’s Compensation	YES	NO	$		Applied for
Worker’s Compensation	YES	NO	$		Denied
					Denied
Disability/Sick Benefits	YES	NO	$		Applied for
Disability/Sick Benefits	YES	NO	$		Denied
					Denied
Union Benefits	YES	NO	$		Applied for
Union Benefits	YES	NO	$		Denied
					Denied
Unemployment Benefits	YES	NO	$		Applied for
Unemployment Benefits	YES	NO	$		Denied
					Denied
Lump Sum Cash Amounts	YES	NO	$		Applied for
Lump Sum Cash Amounts	YES	NO	$		Denied
					Denied
Interest/Dividends from Stocks,	YES	NO	$		Applied for
Bonds, Savings, or other investments	YES	NO	$		Denied
Bonds, Savings, or other investments					Denied
Other
Please describe:	YES	NO	$		Applied for
	YES	NO	$		Denied
					Denied

Other
Please describe:	YES	NO	$		Applied for
	YES	NO	$		Denied
					Denied

Other
Please describe:	YES	NO	$		Applied for
	YES	NO	$		Denied
					Denied

SECTION T – SPOUSAL NEEDS (SPOUSAL IMPOVERISHMENT): If you have a living spouse, fill in this section. List all assets owned in the month the applicant was admitted to a long-term care facility. Include all assets owned individually or jointly by the applicant, or owned individually or jointly by your spouse.

SEND PROOF Please send copies of statements that verify the value of the assets.

ASSET TYPE	CHECK	OWNER	AMOUNT	ACCOUNT NUMBER	INSTITUTION NAME
ASSET TYPE	ONE	OWNER	AMOUNT	ACCOUNT NUMBER	INSTITUTION NAME
	ONE

Cash on Hand	YES		$
Cash on Hand	NO		$
	NO

Checking Account	YES		$
Checking Account	NO		$
	NO

Savings Account	YES		$
Savings Account	NO		$
	NO

DHR/FIA 9709 (REVISED 7-1-11)					Page 11 of 17

SECTION T – SPOUSAL IMPOVERISHMENT (continued)

	ASSET TYPE	CHECK	OWNER	AMOUNT	ACCOUNT NUMBER	INSTITUTION NAME
	ASSET TYPE	ONE	OWNER	AMOUNT	ACCOUNT NUMBER	INSTITUTION NAME
		ONE

Credit Union Account		YES		$
Credit Union Account		NO		$
		NO

Trust Fund		YES		$
Trust Fund		NO		$
		NO

IRA or Keogh Account		YES		$
IRA or Keogh Account		NO		$
		NO

Other Retirement		YES		$
Accounts		NO		$
Accounts		NO

Stocks and Bonds		YES		$
Stocks and Bonds		NO		$
		NO

Certificates and		YES		$
Money Market Funds		NO		$
Money Market Funds		NO

Treasury or Other		YES		$
Notes		NO		$
Notes		NO

Annuity		YES		$
Annuity		NO		$
		NO

Ownership in a		YES		$
Company		NO		$
Company		NO

Other		YES		$
		NO		$
		NO

Other		YES		$
		NO		$
		NO

Other		YES		$
		NO		$
		NO

SECTION U – RESIDENTIAL, SPOUSAL, OR DEPENDENT ALLOWANCE

Have you or your spouse been in an institution/Long-Term Care Facility in the past?

YES NO

If yes, please provide the following:
Date Entered Institution/
Long-Term Care Facility	Name of the Facility

Is there a spouse, child under 21, or any other dependent relatives at home?

YES

If YES, fill in the section below. If you need additional space for assets for dependent children and relatives at home, please use Section V or attach additional sheets.

				GROSS			VALUE OF
NAME	RELATIONSHIP	AGE		MONTHLY	TYPE OF INCOME		ASSET	ASSET TYPE
NAME	RELATIONSHIP	AGE		INCOME
				INCOME
				SEND PROOF			SEND PROOF

			$			$

DHR/FIA 9709 (REVISED 7-1-11)								Page 12 of 17

SECTION U – RESIDENTIAL, SPOUSAL, OR DEPENDENT ALLOWANCE (continued)

				GROSS			VALUE OF
NAME	RELATIONSHIP	AGE		MONTHLY	TYPE OF INCOME		ASSET	ASSET TYPE
NAME	RELATIONSHIP	AGE		INCOME
				INCOME
				SEND PROOF			SEND PROOF

			$			$

			$			$

If applicant/recipient intends to return home within six months and if there is no spouse, child under 21, or other dependent relatives, fill in the section below:

SEND PROOF Please provide your most recent statements to verify the expenses you listed below:

Rent/Mortgage		Utilities	Heat (if separate from utilities)	Property Taxes
$	_	$	$	$

Home Owner’s Insurance		Condo Fees	Other Shelter Costs (Specify)	Other Shelter Costs (Specify)
$	_	$	$	$

SECTION V – ADDITIONAL INFORMATION: Please use this area for any information that would not fit in the spaces provided on this application.

DHR/FIA 9709 (REVISED 7-1-11)

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SECTION W – TAX RETURNS: Please tell us about any tax returns filed by you and/or your spouse in the last five years.

Did you or your spouse file Federal income tax returns in the last five years?

YES

SEND PROOF Please send copies of Federal tax returns for the current year and the preceding four years, including all forms and schedules.

SECTION X – PRE-ELIGIBILITY MEDICAL EXPENSES (NON-COVERED SERVICES): Please tell us about any unpaid medical bills that you incurred in the last three months. You may be eligible for deductions from your income.

Do you have any unpaid medical bills that you incurred in the last three months?

YES

SEND PROOF If you answered yes, provide a newly dated, itemized, unpaid medical bill(s) that you incurred up to three months prior to this application. The bill must contain a service date, charge, and a detailed description of the service(s) provided. Attach copies of the bill(s) to the form and submit them with your Long-Term Care Medical Assistance application. If you do not have the bills at the time you submit the application, the bills may be submitted at a later date during this application process.

Please check one of the YES or NO choices below and sign where you have indicated your choice:

YES, I HAVE unpaid medical bills from the last three months.

I am sending copies of my bills with this application.

I will send copies of my bills at a later date during this application process.

Signature:(Applicant)

Date:_

Signature:

(Authorized Representative)

Date:_

NO, I DO NOT HAVE unpaid medical bills at this time.

Signature:(Applicant)

Date:_

Signature:				(Authorized Representative)
Date:
DHR/FIA 9709 (REVISED 7-1-11)				Page 14 of 17

MARYLAND DEPARTMENT of HUMAN RESOURCES

MARYLAND DEPARTMENT of HEALTH and MENTAL HYGIENE

LONG-TERM CARE/WAIVER MEDICAL ASSISTANCE APPLICATION

RIGHTS AND RESPONSIBILITIES

I UNDERSTAND I HAVE THE FOLLOWING RIGHTS:

The Department cannot discriminate against me. Federal and State law prohibit the Department from discriminating against me because of race, color, national origin, sex, age, or disability. If I think the Department has discriminated against me, I may contact the U.S. Department of Health and Human Services at: HHS, Director, Office for Civil Rights, Room 506-F, 200 Independence Avenue, S.W., Washington, D.C. 20201 or by calling 202- 619-0403 (voice) or 202-619-3257 (TDD).

I have the right to privacy of my personal information. I am providing personal information (that includes, but is not limited to: name, address, date of birth, Social Security number, income history, employment history, medical history) in this application for Medical Assistance. The purpose of requesting this personal information is to determine my eligibility for Medical Assistance. If I do not provide this information, the Department may deny my application for benefits. I have a right to inspect, amend, or correct this personal information. The Department will not permit inspection of my personal information, or make it available to others, except as permitted by Federal and State law. I understand, however, that the Department may deny my application for Medical Assistance if I do not provide this information.

If my case is approved, the Department will provide me with a written notice explaining my benefits. The Department must give me written notice when it changes my benefits or, determines that I am ineligible for Medical Assistance. I have 90 days from the date of the notice to request a hearing. If I am already receiving benefits and request a hearing within 10 days from the date of the notice, I may continue to receive benefits while I wait for the hearing. Any erroneous benefits I receive from the Department must be repaid to the Department.

I have the right to appeal certain actions taken by the Department. I can request a hearing if: my application for Medical Assistance eligibility is denied; I assert the Department’s decision about Medical Assistance services was erroneous; or, there was a delay in the Department’s action(s) related to my application. I may call the Department at 1-800-332-6347 for help requesting a hearing. I am responsible for providing the reason for requesting a hearing. At the hearing, I may speak for myself or I may be accompanied by a lawyer, friend, or relative to speak on my behalf.

IF I ACCEPT MEDICAL ASSISTANCE, I UNDERSTAND BY SIGNING THIS APPLICATION:

Payment Authorization - I authorize payment under Medicare Part B to be made directly to health care providers and medical suppliers.

Assignment of Health Insurance/Third Party Payments - I assign all rights, title, and interest of health insurance payments I may have to the Department and give the Department the right to seek payment from private or public health insurance and any liable third party for the costs the Department incurs for the benefits I receive under Medical Assistance. The Department may seek payment without legal action, providing it does not keep more than the amount Medical Assistance paid. I agree to promptly forward, to the Department, any health insurance payments I receive, including payments received as a settlement from an accident.

Access to Records - I give the Department the right to inspect, review, and copy all relevant portions of my medical records for purposes of determining my eligibility for, and for determining the appropriateness of the services received through, the Medical Assistance program.

Quality Review Cooperation - I understand that the Department may select my case for a random check or audit for quality control purposes. I agree to allow any representative from the Department to visit me where I reside. I will fully assist the Department in retrieving all proof needed from any source.

Estate Recovery - I understand that the Department may recover, from the estate of a deceased Medical Assistance recipient, Medical Assistance payments made on his or her behalf on or after the person attained age 55. The Department may recover only if there is no surviving spouse, unmarried child younger than 21, or blind or disabled child (married or unmarried) of any age.

Accurate and Confidential Application Information - I acknowledge that I must provide true, correct, and complete information and provide proof of this information.

DHR/FIA 9709 (REVISED 7-1-11)

Page 15 of 17

Social Security Number(s) - I must provide my (and my spouse’s) Social Security number as an applicant for Medical Assistance. The Department will use the Social Security number(s) and other information I provide to verify the information I provide for program reviews. The Department will do this to make sure I am eligible. The Department may also verify my information by contacting my employer, bank, or other parties; and/or, the Department may contact local, State, or Federal agencies to make sure the information I provide is correct. If I do not have a Social Security number, I must apply for one and the Department can provide assistance in applying for a number.

Accurate Financial Reporting - I understand that I am responsible for reporting true, correct, and complete financial information. This includes, but is not limited to information about: all my assets; potential assets; transfer of assets within the last 5 years of my initial application; transfer of assets within the last 12 months of the date of the annual redetermination of my eligibility; income; insurance; real property; annuities; and all other benefits I may be receiving. I understand that Federal law requires that, as a condition of receiving long-term care services, the Department must be named, in my annuity, as the primary remainder beneficiary.

Report Changes - I am responsible for reporting changes in my situation. I must report changes within 10 days. The best way for me to report changes is in writing. Examples of changes in my situation are changes in my income, assets, address, health insurance premiums, or persons living in my home. My representative (person acting on my behalf who may file my application) is responsible for reporting such changes. Changes must be reported to the appropriate Local Department of Social Services or the Bureau of Long-Term Care Eligibility.

Medical Assistance Card Misuse - If I become eligible for Medical Assistance, I must use my Medical Assistance card properly. It is against the law to allow another person to use my card.

Medical Assistance Fraud - If I do not report true, correct, and complete information, or report changes, the Department may deny, stop, or reduce my benefits. A judge may fine me and/or imprison me if I intentionally do not give correct information or report changes.

SIGNATURES:

I swear or affirm that I have read or had read to me this entire application. I also swear or affirm, under penalty or perjury, that all the information I have given is true, correct, and complete to the best of my ability, knowledge and belief. I have received a copy of my rights and responsibilities. I authorize any person, partnership, corporation, association, or governmental agency which knows the facts relevant to determining my eligibility to release that information to the Department. I also authorize the Department to contact any person, partnership, corporation, association, or governmental agency that has provided information relevant to my eligibility for benefits. I certify, under penalty of perjury, by signing my name below, that the person for whom I am applying is a U.S. citizen or lawfully admitted immigrant.

Signature of

Applicant/Recipient

Date_

Signature of Witness

(If you Signed an X)

_ Date_

Signature of Spouse

(If applicable)

_ Date_

Signature of Authorized

Representative (if applicable)

_ Date_

I withdraw my application for Medical Assistance

Signature of Applicant, Recipient, or Authorized Representative

Date

Signature of Case Manager

Date

DHR/FIA 9709 (REVISED 7-1-11)

Page 16 of 17

MARYLAND DEPARTMENT of HUMAN RESOURCES

MARYLAND DEPARTMENT of HEALTH and MENTAL HYGIENE

LONG-TERM CARE/WAIVER MEDICAL ASSISTANCE APPLICATION

DECLARATION

I swear or affirm, under penalty of perjury, that all information, including financial information, I have provided on this application is true, correct, and complete to the best of my knowledge. The requirement to report true, correct, and complete information includes the requirement to report financial changes that may affect my eligibility for benefits. Federal and State law requires that I disclose all transfers or gifting of assets within the 60 month (5 year) period prior to the month of application.

I understand that if I knowingly do not tell the truth, hide information, pretend to be someone else, or withhold information about myself (and my spouse, if any) or about the person for whom I am applying (and that person’s spouse, if any), I may be breaking the law. Information provided on the application may be verified or investigated by Federal, State, and local officials including Federal and State Quality Control staff.

The consequences of not complying with the law are: my benefits may be denied; I may be required to pay back the State for benefits received; my case may be investigated for suspected fraud; and I may be prosecuted for perjury, larceny, and/or Federal health care fraud [not limited to Statute 42 U.S.C. sec. 1320a-7b(a)(ii)], which may involve a fine up to $10,000 per offense and/or federal imprisonment.

Signature of Applicant/Recipient	Date

Signature of Witness (If signed with X)	Date

Signature of Spouse (If applicable)		Date

Signature of Authorized Representative (If applicable)		Date

DHR/FIA 9709 (REVISED 7-1-11)

Page 17 of 17

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