Michigan Dhs 4574 Form is required to be filed in order to get the child tax credit. The form is used to calculate the amount of the credit that can be claimed for each qualifying child. The credit is available for taxpayers who have children under age 17 at the end of the tax year. There are a number of requirements that must be met in order to claim the child tax credit, and it is important to understand these requirements before filing your return. The Michigan Dhs 4574 Form can be complex, so it is important to seek assistance if you are not sure how to complete it.
Below is the information concerning the form you were seeking to fill out. It will show you how much time it will take to fill out michigan dhs 4574, exactly what parts you need to fill in, and so on.
Question | Answer |
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Form Name | Michigan Dhs 4574 |
Form Length | 12 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 3 min |
Other names | application for medicaid for nursing home care, michigan medicaid application, michigan form medicaid application, michigan application medicaid form |
APPLICATION FOR HEALTH CARE COVERAGE
PATIENT OF NURSING FACILITY
Michigan Department of Health and Human Services
HELP IS AVAILABLE
FOR OFFICE USE ONLY
Beneiciary Name
Client ID
Case Number
County |
District |
Section |
Unit |
Specialist |
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The Michigan Department of Health and Human Services must help all persons ill out the application, when requested. If you need help, please call or visit your specialist or the ofice named below. If you need an interpreter, the Department will provide one free of charge or you may use one of your choice. If you are refused help in illing out the application, call
Do you need the Department to provide an interpreter to help you at the interview? c Yes |
c No |
If yes, what language? _____________________ |
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El Michigan Department of Health and Human Services debe ayudar a todas las personas a completar la aplicacion cuando asi lo piden. Si usted necesita ayuda, por favor llame o visite a su especialist o la oicina el nombre debajo. Si necesita un interprete, el departmeto le proporcionará
uno gratis o usted puede usar uno de su eleccion. Si usted es negado ayuda para completar la aplicacion, puede llamar al
¿Necesita que el Departamento proporcione un interprete para que le ayude en la entrevista? c si c no
Si dice que si, ¿en que idioma? __________________
.ﻚﻟذ ﻢﮭﻨﻣ ﺐﻠﻄﯾ ﺎﻣﺪﻨﻋ ،تارﺎﻤﺘﺳﻻا ءﻞﻤﻟ صﺎﺨﺷﻻا ﻊﯿﻤﺟ ةﺪﻋﺎﺴﻣ نﺎﻐﯿﺸﯿﻣ ﺔﯾﻻﻮﻟ ﺔﯿﻧﺎﺴﻧﻻاو ﺔﯿﺤﺼﻟا تﺎﻣﺪﺨﻟا ةرادا ﻰﻠﻋ ﺐﺠﯾ ﺔﺟﺎﺤﺑ ﺖﻨﻛ اذأ . هﺎﻧدا ﮫﻤﺳا دراﻮﻟا ﺐﺘﻜﻤﻟا وا ﻚﺘﻟﺎﺤﺑ ﺮﻈﻨﯾ يﺬﻟا ﻲﺋﺎﺼﺧﻻا ةرﺎﯾز وا لﺎﺼﺗﻻا ﻰﺟﺮﯾ ،ةﺪﻋﺎﺴﻤﻟا ﻰﻟا ﺔﺟﺎﺤﺑ ﺖﻨﻛ اذإ ،ﺐﻠﻄﻟا ءﻞﻤﺑ ﻚﺗﺪﻋﺎﺴﻣ ﺾﻓر ﻢﺗ اذا .ﺐﻏﺮﺗ ﻦﻣ رﺎﯿﺘﺧا ﻚﺘﻋﺎﻄﺘﺳﺎﺑ وأ ﻞﺑﺎﻘﻣ نوﺪﺑ ﻚﻟ ﻢﺟﺮﺘﻣ ﺮﯿﻓﻮﺘﺑ ةرادﻻا مﻮﻘﺘﺳ ، ﻢﺟﺮﺘﻣ ﻰﻟا
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ﻢﻌﻧ ؟ ﺔﻠﺑﺎﻘﻤﻟا ءﺎﻨﺛا كﺪﻋﺎﺴﯾ ﻲﻛ ﺎﻤﺟﺮﺘﻣ ﻚﻟ ﺮﻓﻮﺗ نا ةرادﻻا ﻦﻣ ﻦﯾﺮﺗ ﻞھ |
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____________________ ؟ ﺎﮭﺑ ﻢﻠﻜﺘﺗ ﻲﺘﻟا ﺔﻐﻠﻟا ﻲھ ﺎﻤﻓ ﻢﻌﻨﺑ ﺖﺒﺟا اذإ |
El Michigan Department of Health and Human Services (MDHHS) no discrimina contra ningún individuo o grupo a causa de su raza, religión, edad, origen nacional, color de piel, estatura, peso, estado matrimonial, información genética, sexo, orientación sexual, identidad de sexo o expresión, creencias políticas o incapacidad.
PLEASE READ CAREFULLY
FOR NURSING FACILITY PATIENTS ONLY
Complete this form if you are in a nursing facility. Please read each item carefully before you answer it. The answers you give will be used to determine if you are eligible for health care coverage. Be sure to sign your name on pages 2 and 4.
You can apply for health care coverage by mailing or having someone take this form into your local Michigan Department of Health and Human Services (MDHHS) ofice. Your application must be approved or denied
within:
•45 days, or
•90 days if disability is a factor in determining your health care coverage eligibility.
Use
LOCAL OFFICE:
The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.
AUTHORITY: |
42 CFR PART 435. |
COMPLETION: |
Voluntary. |
PENALTY: |
No Healthcare Coverage. |
FOR OFFICE USE ONLY
NOTES
FOR OFFICE USE ONLY
NOTES
FOR OFFICE USE ONLY
NOTES
ASSETS DECLARATION
PATIENT AND SPOUSE
Michigan Department of Health and Human Services
(Skip if no spouse)
FOR OFFICE USE ONLY
Beneiciary Name
Client ID
Case Number
County |
District |
Section |
Unit |
Specialist |
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PLEASE PRINT
Patient’s Name (First, Middle, Last) |
Phone No. of Nursing Home |
Spouse’s Name (First, Middle, Last) |
Spouse’s Phone No. |
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Address of Nursing Home (Number, Street, Rural Route) |
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Spouse’s Address (Number, Street, Rural Route) |
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City |
State |
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Zip Code |
City |
State |
Zip Code |
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Patient’s Birthdate (Mo/Day/Yr) |
Patient’s Social Security |
Spouse’s Birthdate (Mo/Day/Yr |
Spouse’s Social Security* |
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This form asks questions about the property or assets owned by you and/or your spouse. This information is needed to determine your eligibility for Healthcare Coverage and the amount of assets that can be protected for the beneit of your spouse. Answer the following questions by providing information about all assets owned by you and/or your spouse as of _________________________.
Include assets you or your spouse own jointly with family or other persons.
ASSETS
1. Do you and/or your spouse have any assets (include assets held jointly)? |
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c Yes |
4Check all types of assets your household has and complete the table |
c No |
c c c
Checking/draft account Certiicates of Deposit (CD)
Case on hand or in safe deposit
c c c
Money market accounts Christmas club accounts
Savings, bonds, stocks or mutual funds
c c c
Savings/share accounts
Patient trust fund
IRA, KEOGH, 401K or Deferred
Compensation account(s)
c Trust or Annuity |
c Land contract, mortgage or other |
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notes payable to household member |
cReal estate (including place you live)
c c c
Life estate/life lease |
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c Burial plot(s), casket, etc. |
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c Tools, equipment, livestock or crops |
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Life insurance |
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c Other Assets ___________________ |
c Health Savings Account |
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Burial trust/funeral contract(s) |
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Type(s) |
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Name and address |
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Account/policy |
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Owner(s) |
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Balance |
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of asset(s) |
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of Asset(s) |
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amount of value |
(bank, insurance company, etc.) |
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number, etc. |
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The Michigan Department of Health and Human Services (MDHHS) does not |
AUTHORITY: |
42 CFR Part 435. |
discriminate against any individual or group because of race, religion, age, |
COMPLETION: |
Voluntary. |
national origin, color, height, weight, marital status, genetic information, sex, |
PENALTY: |
No Healthcare Coverage. |
sexual orientation, gender identity or expression, political beliefs or disability. |
*Optional if the community spouse is not requesting assistance.
1 |
ASSETS
2. Does anyone in your household have any vehicles?
c Yes |
4Check all types of assets your household has and complete the table |
c No |
c Car |
c Truck c Boat |
Owner(s)
(As shown on vehicle title
or registration)
c Camper/trailer |
c Motorcycle |
c RV |
c Other Vehicle |
Year |
Make/Model |
Amount Owed |
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3. Has anyone in your household:
•sold or given away property, land, vehicles, stocks, bonds, savings, cash, checking, income, etc., closed any accounts or removed or added a name on any asset within the last 60 months?
•iled a pending lawsuit which may bring money, property, etc.?
•received a
•or has anyone acting for any household member, ever put any money, lawsuit settlement, income or assets in a trust, annuity or similar legal device?
c Yes 4Who:
cNo
cYes 4Who:
cNo
cYes 4Who:
cNo
cYes 4Who:
cNo
AFFIDAVIT
I swear or afirm that all the information that I have written on this form or told to a specialist is true. I understand that I can be prosecuted for perjury if I have intentionally given false information. I also know that I may be asked to show proof of any information I have given. I also know that if I have intentionally left out any information or if I have given false information, which causes me to receive assistance I am not entitled to or more assistance than I am entitled to, I can be prosecuted for fraud.
Estate Recovery. I understand that upon my death the Michigan Department of Health and Human Services (MDHHS) has the legal right to seek recovery from my estate for services paid by Healthcare Coverage. This means that some or all of my estate may be recovered. MDHHS will not seek to recover against the estate while there is a legal surviving spouse or a legal surviving child who is under the age of 21, blind, or disabled. An estate consists of real and personal property. If you have received an asset disregard due to a
Signature (Patient or Representative)
Date (Month, Day, Year)
Two Witnesses Only If Signed by Mark X
Signature of First Witness
Signature of Second Witness
NOTE: If you signed this application on behalf of someone else, complete the information below.
Name (First, Middle, Last)
Phone Number
Relationship to Patient
Street Address
City
State
Zip Code
2 |
Note: This application requests information about the patient in the nursing facility.
The words “You” and “Your” refer to the patient.
1. |
Patient’s Name (First, Middle, Last) |
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Name of Nursing Facility |
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3. Address of Nursing Facility |
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City |
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State |
Zip Code |
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4. |
Phone No. of Nursing Facility |
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5. County |
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6. |
Birthdate |
7. Sex |
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8. Social Security Number |
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Marital Status: c Never married |
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c Married |
c Separated c Divorced |
c Widowed |
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10. Date of Nursing Facility Admission |
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11. Address where you lived before you entered the nursing facility |
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12.If married, tell us about your spouse and all persons living with your spouse. If not married, tell us about your children under age 18 living in your home.
Name |
Date of Birth |
Social Security Number* |
Relationship to you |
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If you have a |
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13. Name of Guardian/Conservator |
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Phone Number |
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Do you pay guardian/conservator |
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expenses? |
c YES |
c NO |
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Guardian’s/Conservator’s Address |
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City |
State |
Zip Code |
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YES NO
14.Have you ever applied for or received
assistance in Michigan? |
c |
c |
15.Have you received money or beneits such
as Medical Assistance from another state in the last 30 days?
c c
21.Do you have unpaid medical expenses for services provided in the last 3 months?
22.Do you pay health insurance premiums?
23.Do you have Medicare Coverage? Do you need help paying premiums?
YES NO
c c
c c
c c
c c
16. |
Are you a U.S. citizen or U.S. national? |
c |
c |
24. |
Are you covered by a health, hospital, or |
17. |
If you are not a U.S. citizen or U.S. national, do you have |
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covered in the last 3 months? |
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eligible immigration status? If Yes: |
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25. Has a court ordered anyone to pay your |
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a. Immigration document type ______________ |
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b. Document ID number ___________________ |
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medical expenses or provide health |
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c. Have you lived in the U.S. since 1996? |
c |
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insurance for you? |
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d. Are you, or your spouse or parent a veteran or an |
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26. |
Have you had an accident or |
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c |
c |
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illness or injury resulting in medical costs |
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e. U.S. entry date ______________________ |
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that may be paid by another person or an |
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18. |
Enter your racial heritage from codes below. If you are |
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insurance company? |
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multiracial, enter all the codes that apply (answering |
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is voluntary) I = American Indian, A = Alaskan Native, |
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27. |
Have you set up a plan or entered into a |
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S = Asian, B = Black or African American, |
P = Native |
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contract, such as a life care contract, that |
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Hawaiian or Other Paciic Islander, W = White |
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will pay for your medical care? |
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_____________________________ |
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19. |
Check the box if you are Hispanic or |
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28. Is there a plan for you to return home |
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Latino (answering is voluntary). |
c |
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within six months from the date of |
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admittance? |
20. |
Are you a veteran or the spouse, |
c |
c |
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dependent or parent of a veteran? |
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*Optional if the community spouse and/or children are not applying for Healthcare Coverage.
c c
c c
c c
c c
c c
3 |
29.Assets: Complete the assets section by providing the requested asset information for you and your spouse. List your assets and your spouse’s assets. Include assets you own jointly with family or other persons, including your spouse. Include assets your spouse owns jointly with you, family or other persons. Each item must be answered YES or NO. If answered
YES, enter amount or current value and owner(s).
Type of Asset |
YES NO |
Amount or Value |
Owner(s) of Asset |
Has anyone in your household received a federal tax refund in the last 12 months?
Cash on hand, in a safety deposit box or
patient trust fund
Home, life estate/life lease
Real estate, not your home
Mortgage, land contract or other notes payable to you
Savings bonds or money market funds
Stocks or mutual funds
Pension, IRA, KEOGH, 401K or deferred
compensation account(s)
Trust funds
Life Insurance
Annuity
Cars, vans, trucks, campers, boats, snow- mobiles, other vehicles
Tools, equipment, livestock, or crops
Funeral contracts
Burial plot, casket, etc.
Health Savings Account
Are there any other assets? (Please Explain)
Checking/Draft Accounts — Savings/Share Accounts — Certiicates of Deposit
Name(s) on the Account
Name and Address of Bank
Credit Union, Savings and Loan
Account Number
Balance
YES NO
30.Have you received a
settlement, lawsuit award, worker’s compensation, lottery winnings, etc.? |
c |
c |
31. Do you have a pending lawsuit that may bring property or money to you? |
c |
c |
32.Within the last 60 months (5 years) have you or a joint owner or other person whose name is also listed on the asset:
• |
sold, given away, or transferred ownership in any asset such as those listed above? |
c |
c |
• |
removed or added a name on any asset such as those listed above? |
c |
c |
33.Have you or someone acting for you ever put any money, income, lawsuit settlement or assets in a
trust, annuity or similar device? |
c |
c |
4 |
34.Income: Include income for yourself and everyone listed in question 12.
Is anyone employed or
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How often paid: weekly, |
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deductions |
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Every item below must be answered YES or NO. |
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Type of Income |
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YES |
NO |
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Amount |
Whose Income |
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Social Security Beneits (RSDI) Claim # |
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Social Security Beneits (RSDI) Claim # |
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Supplemental Security Income (SSI) |
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Supplemental Security Income (SSI) |
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Retirement Beneits |
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Veterans Beneits |
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Disability Beneits |
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Rental Income |
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Worker’s Compensation |
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Child Support |
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Unemployment Compensation |
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Military Allotments |
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Gaming Distributions (Casino Proit Sharing) |
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Is there any other income? (Please explain) |
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35. |
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Address where your spouse lives |
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Spouse’s Phone Number |
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Household Expenses |
Check YES or NO and write in the answer about you and/or your spouse’s home. |
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YES |
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NO |
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AMOUNT |
HOW OFTEN PAID |
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Do you and/or your spouse have a rent, mortgage or other shelter |
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expense? |
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Do you and/or your spouse have the following expenses separate from rent or mortgage: |
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Renter’s Insurance |
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• |
Property Taxes |
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• Mobile Home Lot Rent |
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Special Assessments |
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Homeowner’s Insurance |
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Mortgage Guarantee Insurance |
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• Cooperative or Condominium Fee |
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Do you and/or your spouse have an obligation to pay for heat and/ |
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or utilities? |
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5 |
ASSIGNMENT OF BENEFITS
Recovery of Medical Costs. I understand that when the Michigan Department of Health and Human Services
(MDHHS) pays the cost of hospital, surgical, or medical services, any right to recover costs from a third person or public or private contractor, except Medicare, is transferred to the MDHHS. Payment of any recovery under such right is to be made directly to the State of Michigan — MDHHS.
RELEASES
Social Security Information. I will allow the Social Security Administration to give to the MDHHS all information necessary to determine my eligibility for beneits under the Healthcare Coverage program until the second month following the expiration of my eligibility based on the current application.
Eligibility Information. I understand that the information I have provided will be used to determine my eligibility for Healthcare Coverage only and for purposes of administering the Healthcare Coverage program.
AFFIDAVIT
Under penalties of perjury, I swear that this application has been examined by or read to me, and, to the best of my knowledge, the facts are true and complete. If I am a third party applying on behalf of another person, I swear that this application has been examined by or read to the applicant, and, to the best of my knowledge, the facts are true and complete.
I certify, under penalty of perjury, that all information that I have written on this form or told to a specialist is true. I understand that I can be prosecuted for perjury if I have intentionally given false information. I also know that I may be asked to show proof of any information I have given. I also know that if I have intentionally left out any information or if I have given false information, which causes me to receive assistance I am not entitled to or more assistance that I am entitled to, I can be prosecuted for fraud. I understand I must report changes in income, assets or health insurance coverage to the department within 10 days of the change.
If you have any questions, contact your specialist or the local MDHHS before signing the application.
I understand that upon my death the Michigan Department of Health and Human Services (MDHHS) has the legal right to seek recovery from my estate for services paid by Healthcare Coverage. This means that some of all of my estate may be recovered. MDHHS will not seek to recover against the estate while there is a legal surviving spouse or a legal surviving child who is under the age of 21, blind, or disabled. An estate consists of real and personal property. If you have received an asset disregard due to a
IMPORTANT: YOU MUST SIGN THE APPLICATION
I certify that I have received and reviewed a copy of the Acknowledgments that explains additional information about applying for and receiving Healthcare Coverage.
Signature (Patient or Representative) |
Date |
Two Witnesses only if signed by X |
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Signature (Patient or Representative) |
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Two Witnesses only if signed by X |
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If you are signing this application on behalf of someone else, complete the information below.
Name of person completing application |
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Relationship to patient |
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6 |
PLEASE KEEP THIS PAGE.
Tear out along the dotted line.
INFORMATION ABOUT HEALTHCARE COVERAGE
Rules may have changed since this was printed. Check with your local MDHHS ofice.
“You” and “Your” below refer to the patient. “We” means the Michigan Department of Health and Human Services.
If you need help with past, unpaid medical expenses, Healthcare Coverage may begin three months before you apply. You can have Healthcare Coverage even if you are not a U.S. citizen. Coverage might be limited to just emergency services. There are limits on the amount of income and assets you can have and be eligible for Healthcare Coverage.
Receiving Healthcare Coverage Services
You must tell all your providers (doctors, hospital, pharmacy, etc.) that you have applied for Healthcare Coverage before you receive any new medical services. Not all providers accept Healthcare Coverage. Choose a provider who does accept Healthcare Coverage.
You must give your medical provider a copy of your mihealth card or approval letter as soon as it is received. This letter tells when your eligibility began. Your providers need this information to receive prompt payment for medical services provided to you. This information is needed to issue you a refund if you pay for a Healthcare Coverage service before you received the approval letter.
We might approve Healthcare Coverage for up to 3 months before you applied. If we do, ask your providers to bill Healthcare Coverage for any covered services you received during those months. If you paid for any of these bills before you received the approval letter, ask your health providers if they will refund your money and bill Healthcare Coverage. Providers are not required to do this, but many will.
Your providers must submit your bills to Healthcare Coverage within 12 months after the date you received the services. If they wait more than 12 months, then Healthcare Coverage may not pay the bill unless the delay in billing is because you had to ile an appeal to get Healthcare Coverage beneits.
Income
You meet the income test if your income is not enough to pay your medical expenses. Usually you will pay part of your nursing facility expenses and Healthcare Coverage will pay the rest. If you have a spouse or children at home, a portion of your income might be protected for them.
We count income such as Social Security beneits, pensions, rent income and veterans beneits. Assets
Countable assets must be at or below the $2,000 asset limit at least part of each month for which Healthcare Coverage is requested. If you have a spouse at home:
We count your assets and your spouse’s assets initially. We protect a substantial amount of assets for your spouse. The remainder cannot exceed $2,000 for you to be eligible for Healthcare Coverage.
Once initial eligibility is established, we only count your assets. The asset limit is $2,000.
If your assets are more than the asset limit, you may become eligible for Healthcare Coverage if you use your excess assets to pay some of your medical bills, living expenses, or other debts. You may be asked to verify when and for what purposes you used your excess assets.
Healthcare Coverage might not pay for your care if you or your spouse transfer assets or income for less than fair market value. We look at transfers that occur up to 60 months (5 years) before, or any time after, your irst date of application for Healthcare Coverage while in a nursing facility.
Nursing Facility Eligibility (MDCH Publication 726) - explains eligibility for persons in or entering a nursing facility.
The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.
ACKNOWLEDGMENTS
Michigan Department of Health and Human Services
This is your copy of your rights and responsibilities as an applicant for or recipient of Healthcare Coverage beneits. By signing the
application you acknowledge that you understood your rights and responsibilities and that you applied only for Healthcare Coverage.
ASSIGNMENT OF BENEFITS
1.Recovery of Medical Costs. I understand that when the Michigan
Department of Health and Human Services (MDHHS) pays the cost of hospital, surgical, or medical services, any right to recover costs from a third person or public or private contractor, except Medicare, is transferred to the MDHHS. Payment of any recovery under such right is to be made directly to the State of Michigan -
MDHHS.
ACKNOWLEDGEMENTS
2.
3.Reporting Changes. I understand that the department needs to know about changes that may affect my Healthcare Coverage. I will tell the department of any changes within 10 days of the change. I understand that if I intentionally do not do this, I can be prosecuted for fraud or perjury.
The types of changes that MUST be reported are:
•Receipt of or increase in income such as social security, veterans beneits, railroad retirement, pensions, retirement, disability or sick beneits.
•Discharge or move from the nursing facility to another living arrangement.
•Changes in health or hospital insurance coverage or amount of premiums.
•Any accident or
•Another person or an insurance company has agreed to pay my medical expenses or is ordered to by the court.
•Receipt of a sum of money.
•Receipt of an inheritance, bank account, or other property or income from or on behalf of another person.
If you have any doubt about whether you should report a change in circumstances, ask your local MDHHS.
4.Hearings. I understand that if I do not agree with any decision made on any matter concerning my case I have the right to ask for an Administrative Hearing. I understand that I can ask for information about an Administrative Hearing by calling my local
MDHHS.
I understand that if I want someone else to request a hearing for me or represent me in a hearing, that person must irst have written au- thorization to do so unless that person is my attorney or my spouse.
The MDHHS Administrative Hearings must have one of the following:
•my original signed statement authorizing the person to request a hearing, or
•a copy of the court order naming the person as my guardian or conservator.
Otherwise, my hearing request will be denied.
5.Repayment of Beneits. I understand that if I receive more beneits than I am entitled to receive, through my fault, I may have to repay any extra beneits.
6.Immigration Status. I understand that, as part of determining my eligibility for Healthcare Coverage, information about me may be submitted to the Bureau of Citizenship and Immigration Services in order to verify my immigration status.
7.Investigations. I understand that my application might be one of those chosen for a complete investigation and an MDHHS
representative might call on me and might contact other people in order to verify my eligibility for assistance.
8.Computer
Wages reported by my employer(s) to the Department of Labor and Economic Growth will be checked against wage information I report to the MDHHS. My Social Security Number will be used to check this information. Throughout the year, my Social Security Number will also be checked with other sources such as the Internal Revenue Service (IRS), Unemployment Compensation, and the Social Security Administration concerning income or assets.
The information obtained through this
9.Medical Information. By signing this application, I understand that the MDHHS may get and use* necessary medical information about me or any of my wards or my minor children, including any information relative to HIV, ARC or AIDS, if applicable. This information will only be obtained and used as necessary to determine eligibility for a speciic program or for other program administration purposes.
*Some examples of uses are with auditors, caregivers, etc. State law (MCL 333.5131 (8)) provides that a person who shares HIV, ARC or AIDS information except as authorized by this release or by law may be found “guilty of a misdemeanor punishable by imprisonment for not more than 1 year or a ine of not more than $5,000.00, or both, and is liable in a civil action for actual damages or $1,000.00, whichever is greater, and costs and reasonable attorney fees.”
10.Social Security Information. I will allow the Social Security Administration to give to the MDHHS all information necessary to determine my right to beneits under Healthcare Coverage until the second month following the expiration of my eligibility based on the current application.
11.Eligibility Information. I understand that the information I have provided will be used to determine my eligibility for Healthcare Coverage only and for purposes of administering the Healthcare
Coverage Program.
12.Estate Recovery. I understand that upon my death the Michigan
Department of Health and Human Services (MDHHS) has the legal right to seek recovery from my estate for services paid by Healthcare Coverage. This means that some or all of my estate may be recovered. MDHHS will not seek to recover
against the estate while there is a legal surviving spouse or a legal surviving child who is under the age of 21, blind, or disabled. An estate consists of real and personal property. If you have received an asset disregard due to a
recipients who received Healthcare Coverage services after the effective date of the estate recovery statute. MDHHS may agree not to pursue recovery if an undue hardship exists. An application must be submitted to determine if the applicant qualiies for an undue hardship waiver. Undue hardship waivers are temporary. For further information regarding Estate Recovery, call