Medicaid Application Pa 600L Form – Fill Out and Use This PDF

The Medicaid Application Pa 600L form is a crucial document for individuals seeking financial eligibility for Medical Assistance (Medicaid) for long-term care, supports, and services. It's designed to gather comprehensive information about the applicant's financial situation to determine eligibility for assistance. Whether you are applying for care in a facility, home and community waiver services, or other types of support, it's essential to fill out this form carefully and accurately. Ready to secure the support you need? Click the button below to start filling out your Medicaid Application Pa 600L form.

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Medicaid Application Pa 600L Form PDF Details

Navigating the complexities of applying for Medical Assistance (Medicaid) for long-term care, supports, and services can be daunting, but understanding the PA 600L form is a vital first step. This form serves as the financial eligibility application for individuals seeking aid for care in a facility, home and community waiver services, among other supports. Interested applicants have the option to submit their application online or directly to their county assistance office, where additional aid in completing the form is available. It is essential that applicants or their representatives—their spouse, a friend, a relative, someone with power of attorney, or a medical provider—fill out the form comprehensively, ensuring that all relevant income and resource information is accurately reported. This information is crucial, especially considering that any asset transactions within the last 60 months may impact eligibility. The form requires detailed personal, financial, and insurance information, and applicants must disclose whether they have received long-term care or have unpaid medical bills, which could influence their application. Additionally, the provision of social security numbers allows the state to verify asset information. Once submitted, the county assistance office reviews the application, with a commitment to respond within 30 days regarding eligibility or the need for further documentation.

Question	Answer
Form Name	Medicaid Application Pa 600L Form
Form Length	11 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	2 min 45 sec
Other names	how to application for medicaid pa, apply for pennsylvania medicaid online, pa assistance form application, pennsylvania form medicaid application

Form Preview Example

Medical Assistance (Medicaid)

Financial Eligibility Application for

Long Term Care, Supports and Services

You may also apply online at www.compass.state.pa.us

Check any that you are applying for:

¨Care in a Facility

¨ Home and Community Waiver Services Type/Name of Waiver/Service: ___________________________________________

¨Other __________________________________________________________________________________________________

*Please read the entire application form

*Print the requested information in the unshaded sections

*If you need help, another person can help you or you can get help from your county assistance office

You or any representative you choose may complete this application. Your representative can be your spouse, a friend, a relative, a person who has your power of attorney, or your medical provider. It should be someone who knows and can provide information about your income and resources. If you are married, information in some sections must be completed for both you and your spouse.

After the form is completed, bring it, have someone else bring it, or mail it to the county assistance office unless you are instructed otherwise. The county assistance office will tell you if a face to face interview is needed. You will need proof of identity and verification for other information on the form unless we already have

the information in our records. If you need help to obtain any information ask the county assistance office for help. You should attach verification to this form.

Persons who have given away assets (income or resources) within the past 60 months, or set up or transferred assets to a trust within the past 60 months prior to applying for Medical Assistance for long term care, supports and services may be ineligible for benefits. Because of this requirement, you may need to provide verification of assets owned during the past 60 months even though you may no longer own them. We will use your Social Security Number to get information about your assets for the 60 months prior to your application.

If the information is complete and you have provided the necessary verification (with this form, if possible), the county assistance office will notify you within

30 days of receiving your application if you are eligible, ineligible or if additional information is needed.

	PROVIDER USE

NAME		NUMBER

ADDRESS		NUMBER

DATE OF ADMISSION	DATE OF OPTIONS ASSESSMENT	REQUESTED EFFECTIVE DATE

CONTACT NAME/TELEPHONE NUMBER/ADDRESS

CAO USE

CO.	DIST	RECORD NUMBER	FILE CLEARED BY	APPL. REG. NO.

WORKER I.D.			CASELOAD

¨ AUTHORIZED REASON				CATEGORY

¨ NOT AUTHORIZED REASON				DATE

1	PA 600 L (SG) 8/12

PLEASE CoMPLETE ThE FoLLowing inForMATion For ThE

PErSon rEquESTing MEdiCAL ASSiSTAnCE bEnEFiTS

LAST NAME		FIRST NAME						MIDDLE INITIAL		(JR., SR., I, ETC.)

CURRENT ADDRESS (IF IN A FACILITY, USE FACILITY ADDRESS)			CITY		STATE		ZIP CODE + 4		ADMISSION DATE

DATE MOVED TO THIS ADDRESS	TOWNSHIP			SCHOOL DISTRICT		AREA CODE AND TELEPHONE NUMBER

PREVIOUS ADDRESS (IF IN A FACILITY, GIVE YOUR HOME ADDRESS. IF YOU ARE MARRIED, GIVE YOUR SPOUSE’S ADDRESS.)						AREA CODE AND TELEPHONE NUMBER

Do you want an interpreter?

Yes

If yes, what language? _______________________________________________________________________________________________ __

Do you need your notices in Spanish? ¿Necessita sus avisos en Español?

Yes

Have you ever applied for or received cash or medical benefits or participated in the Supplemental Nutrition Assistance Program (SNAP), formerly known as food stamps, in another county in Pennsylvania or in another state?

Yes

If yes, what State? _______________________________

What county? __________________________________

How long? ____________________________________

Record Number ________________________________

Have you ever applied for or received benefits using a different Social Security Number? If yes, what is the number? ________________________

Yes

Have you previously lived in a nursing facility?

Yes

If yes, provide name: __________________________________________________________________________________________________

Address: ____________________________________________________________________________________________________________

Dates: ______________________________________________________________________________________________________________

2	PA 600 L (SG) 8/12

Complete all information in this section for yourself, your spouse if you are married, and any dependent children or siblings.

1 *Attach an additional sheet of paper if you have more dependents.

RELATIONSHIP	LAST NAME	FIRST NAME	MI JR/SR ALIAS/MAIDEN NAME BIRTH DATE SEX *RACE	SSN

SELF

SPOUSE

DEPENDENT

*For Race: Your benefits will not be affected if you do not wish to answer. Please use one of the following codes:

1. Black 2. Hispanic 3. North American Indian or Alaskan Native 4. Asian or Pacific Islander 5. White (Not Hispanic) 6. Other

2Please answer and sign:

Are you a U.S. Citizen?

Yes

No	If No, check one:

Permanent Resident

Temporary Resident

Refugee

Illegal Alien

Alien #:_______________________________________________________Country of Origin: ______________________________Date of Entry:______________________

Sign to declare your citizenship or alien status as marked above:

SignatureDate

Name and address of sponsor if you have one: ___________________________________________________________________________________________________ ____

_____________________________________________________________________________________________________________________________________________

3Marital Status

Please check one:

Married

Single

Widowed

Divorced

Separated

If you checked widowed, what was the date of your spouse’s death?____________________ Name:_______________________________________________________

If you checked separated, what was the date of separation?____________________ Please complete item #1 above for spouse.

4Military Status

Veteran’s Name_______________________________________________

Please check one:

Veteran

Active Military

National Guard

Reserves

Widow/Spouse or Dependent Child of a Veteran

Branch of Service____________________________ Date Entered__________________Date Left__________________Claim No.____________________________________

3	PA 600 L (SG) 8/12

5	Voter registration (Optional)
5	If you are not registered to vote where	you live now, would you like to apply to register to vote here today?	Yes	No

IF YOU DO NOT CHECK EITHER BOX, YOU WILL BE CONSIDERED TO HAVE DECIDED NOT TO REGISTER TO VOTE AT THIS TIME.

To register, you must: 1) Be at least 18 on the day of the next election; 2) Be a citizen of the United States for at least one month PRIOR TO THE NEXT ELECTION;

3) Reside in Pennsylvania and the voting district at least 30 days prior to the next election.

Applying to register or declining to register to vote will not affect the amount of assistance that you will be provided by this agency.

If you would like help filling out the voter registration application form, we will help you. The decision whether to seek or accept help is yours. You may fill out the application form in private. Please contact the county assistance office if you would like help. If you believe that someone has interfered with your right to register or to decline 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 Secretary of the Commonwealth, PA Department of State, Harrisburg, PA 17120. (Toll-free telephone number 1-877-VOTESPA.)

COUNTY ASSISTANCE OFFICE STAFF WILL COMPLETE THIS BOX BASED UPON YOUR RESPONSE ABOVE

Given to Client __/__/__		Sent to voter registration __/__/__
Declined, not interested __/__/__		Not a U.S. citizen __/__/__
Declined, not interested __/__/__		Not a U.S. citizen __/__/__

Mailed to Client __/__/__ Declined, already registered __/__/__

if you are receiving or have received long term care, supports and services, how were your expenses being paid?

do you have unpaid medical bills?

Yes

no if you are requesting Medical Assistance for these bills, attach copies.

MEdiCAL inSurAnCE inForMATion

(Including Long Term Care Insurance)

INSURANCE

INSURANCE COMPANY

AGREEMENT/

GROUP NAME

EFFECTIVE

PREMIUM

PAID HOW

POLICY HOLDER NAME

DATE OF

COMPANY/MEDICARE

ADDRESS

POLICY NUMBER

NUMBER

COVERAGE

AMOUNT

OFTEN

AND ADDRESS

4	PA 600 L (SG) 8/12

Add an additional sheet of paper if more space is needed. Please label what question number you are answering on any additional pages.

9Complete the following resource information for you and your spouse (if you are married): A. real Estate None

LOCATION

OWNER

VALUE

INCOME PRODUCING		RESIDENT
YES	NO	YES	NO

WHO LIVES IN THE PROPERTY?

IS THE PROPERTY LISTED FOR SALE? IF YES - DATE LISTED
YES	NO

IF FOR SALE GIVE

REALTOR’S NAME AND TELEPHONE NUMBER * REMEMBER TO REPORT THE PROPERTY SALE TO US.

ARE YOU PLANNING TO RETURN TO THE PROPERTY?

YES

DO YOU OWN ANY OTHER REAL ESTATE?

YES

b. Mobile home None

LOCATION		OWNER
YEAR AND MODEL
YEAR AND MODEL
IS THE MOBILE HOME LISTED FOR SALE?	YES	NO
C. burial Arrangements	None

			VALUE	INCOME PRODUCING		RESIDENT
			$	YES	NO	YES	NO
	WHO LIVES IN THE MOBILE HOME?
		REALTOR’S NAME AND TELEPHONE NUMBER
		REALTOR’S NAME AND TELEPHONE NUMBER
IF YES GIVE
	s

BANK/INSURANCE COMPANY NAME AND ADDRESS							ACCOUNT NUMBERS

FUNERAL HOME										VALUE OF ACCOUNT	DATE ESTABLISHED
								$
CAN MONEY BE WITHDRAWN BEFORE DEATH OF INDIVIDUAL?			YES	NO		CAN INTEREST BE WITHDRAWN?			YES	NO

DO YOU OWN ANY BURIAL SPACES?	YES	NO	IF YES		s		NUMBER
			GIVE LOCATION		s		OF SPACES

d. Life insurance	None

COMPANY NAME

POLICY NUMBER

FACE VALUE

CURRENT CASH VALUE

WHO OWNS THE POLICY?

5	PA 600 L (SG) 8/12

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1. The pa medicade application necessitates specific details to be entered. Ensure that the subsequent fields are finalized:

The right way to complete medicaid application pennsylvania part 1

2. After filling in the last section, head on to the subsequent part and fill in the necessary particulars in these fields - aDDress, Number, Worker iD, CaseloaD, Date oF aDmissioN, Date oF optioNs assessmeNt, authorizeD reasoN, CoNtaCt NametelephoNe NumberaDDress, Not authorizeD reasoN, Category, Date, and PA L SG.

medicaid application pennsylvania completion process outlined (part 2)

Those who use this form often get some things wrong when completing Date oF aDmissioN in this part. Be sure you re-examine whatever you type in right here.

3. The following part should be quite simple, last Name, PErSon rEquESTing MEdiCAL, First Name, miDDle iNitial Jr sr i etC, CurreNt aDDress iF iN a FaCility, Date moveD to this aDDress, toWNship, sChool DistriCt, previous aDDress iF iN a FaCility, City, state, zip CoDe, aDmissioN Date, area CoDe aND telephoNe Number, and area CoDe aND telephoNe Number - each one of these empty fields needs to be filled in here.

The right way to fill in medicaid application pennsylvania part 3

4. This particular subsection arrives with these particular form blanks to fill out: Have you ever applied for or, Yes, Have you previously lived in a, Yes, If yes provide name, Address, Dates, and PA L SG.

Step number 4 of completing medicaid application pennsylvania

5. As you draw near to the end of the form, there are actually a few extra requirements that have to be satisfied. Specifically, RElAtIOnShIP, lASt nAmE, FIRSt nAmE, JRSR AlIASmAIDEn nAmE BIRth DAtE, SSn, selF, spouse, DepeNDeNt, For Race Your benefits will not be, Please answer and sign, Are you a US Citizen, Yes, No If No check one, Permanent Resident, and Temporary Resident must be done.

Best ways to fill in medicaid application pennsylvania portion 5

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Medicaid Application Pa 600L Form – Fill Out and Use This PDF

Medicaid Application Pa 600L Form PDF Details

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