Nj Pa 1G Form – Fill Out and Use This PDF

Nj Pa 1G Form PDF Details

Form Preview Example

How to Edit Nj Pa 1G Form Online for Free

Nj Pa 1G Form isn’t the one you’re looking for?

Related Documents

Nj Pa 1G Form – Fill Out and Use This PDF

The NJ PA 1G form serves as an updated Medicaid application, reflecting the significant modifications to the Medicaid program in recent years. Among these modifications are an extended resources section, clarified rights and responsibilities, along with simplified income and resources sectors. For those seeking to navigate these changes efficiently, clicking the button below ensures a smooth process in completing the form.

Get Form Now Download PDF

Nj Pa 1G Form PDF Details

In a notable development within the healthcare sector, the State of New Jersey's Department of Human Services, specifically the Division of Medical Assistance and Health Services, has announced an important update to the Medicaid application process, pivotal for entities such as County Welfare Agency Directors and Institutional Services Section (ISS) Supervisors. This update, encapsulated in the revised Medicaid application form, PA-1G, dated August 15, 2012, represents a significant step towards accommodating the evolving landscape of Medicaid provisions. The modifications introduced in the updated form encompass a broad spectrum of areas, aiming to streamline and simplify the process for applicants. These changes include an expanded Resources section, addressing components like investments, property, and trusts, alongside a clarified depiction of Rights and Responsibilities and a refined articulation of the Income and Resources sections. This effort demonstrates New Jersey's commitment to ensuring that the application process is both inclusive and accessible, reflecting changes in the Medicaid program in recent years. Additionally, the anticipation of the form's translation into Spanish highlights a sensitivity towards linguistic inclusivity, aiming to widen the form's accessibility. This update is not just a procedural change; it signifies a broader intent to evolve with the healthcare needs and circumstances of the state's residents.

Question	Answer
Form Name	Nj Pa 1G Form
Form Length	10 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	2 min 30 sec
Other names	nj medicaid application form, medicaid application form nj, medicaid nj application forms, nj medicaid forms

Form Preview Example

	State of New	Jersey
	DEPARTMENT OF HUMAN SERVICES
	DIVISION OF MEDICAL ASSISTANCE AND HEALTH SERVICES
CHRIS CHRISTIE	P.O. Box 712		JENNIFER VELEZ
Governor	Trenton, NJ 08625-0712		Commissioner
KIM GUADAGNO			VALERIE HARR
Lt. Governor			Director
MEDICAID COMMUNICATION NO. 12-14		DATE: August 15, 2012
TO:	County Welfare Agency Directors
	Institutional Services Section (ISS) Supervisors

SUBJECT: Updated Medicaid Application (PA-1G)

The Division has updated the Medicaid application (PA-1G) to reflect changes in the Medicaid program over the last few years. The major changes include but are not limited to:

-An expanded Resources section (Investments, Property, Trusts, etc.)

-Clarified and updated the Rights and Responsibilities

-Simplified and refined the Income and Resources sections

You may continue to use any unused copies of the previous application before utilizing the attached updated application. We are in the process of having this updated application translated into Spanish, and will distribute that once complete.

If you have any questions regarding this Medicaid Communication, please refer them to the Division’s Office of Eligibility Policy field service staff for your agency at

609-588-2556.

Sincerely,

Valerie Harr

Director

VH:m

Attachment

New Jersey Is An Equal Opportunity Employer

Page 2

c:Jennifer Velez, Commissioner Department of Human Services

Dawn Apgar, Deputy Commissioner Division of Developmental Disabilities

Lowell Arye, Deputy Commissioner Aging and Community Services

Lynn Kovich, Assistant Commissioner

Division of Mental Health and Addiction Services

Joseph Amoroso, Director Division of Disability Services

Raquel Jeffers, Deputy Director

Division of Mental Health and Addiction Services

Kathleen M. Mason, Director Division of Aging Services

Jeanette Page-Hawkins, Director Division of Family Development

Allison Blake, Commissioner Department of Children and Families

Mary E. O’Dowd, Commissioner

Department of Health

MEDICAID APPLICATION

CASE #

Why do you need help at this time?

If disabled, what date did you become disabled?

What is the nature of your disability?

Do you need special assistance to complete this application?

Have you filled out an application before?

Yes

No If yes, where and when?

Based on the above information, please check all program(s) / service(s) requested:

Home & Community Based Services / Waiver

New Jersey Care…Special Medicaid Program

	Nursing Home / Institutional		State of New Jersey
	Assisted Living		Department of Human Services
	NJ WorkAbility

	Medically Needy Program		DMAHS
	Medicaid Only Program

	Other:

This is a legal document and subject to verification. Application must be completed truthfully and accurately.

SECTION I

Basic Information

Applicant’s Name:

Phone #:

Last Name

First

M.I.

Maiden Name

Applicant’s E-mail Address:

Birth Date:

Birth Place:

Social Security #:

(or Railroad Retirement #)

Sex:

Male

Female Marital Status:

Single

Married

Separated

Divorced

Widowed

Child

Do you receive Supplemental Security Income Benefits?

Yes

Date applied for:

Have you been denied SSI benefits within the last 12 months?

Yes

No If yes, why?

Are you a United States Citizen?

Yes

No If no, explain citizenship status:

Alien #

Have you, your spouse, or parent (if applying for a child) served in the U.S. Armed Forces?

Yes

If yes, Name:

VA# (if known):

SECTION II

Residence

Current Residence:

Street

City/Town

State

Zip

Mailing Address (if different):

Do you plan to continue living in New Jersey?

Yes

No If no, explain:

Previous addresses for the past five years: (if additional space is needed, use separate paper)

From

At:

	Signature of Person Initiating Application			Date

	Relationship to Applicant – Parent, Spouse, Legal Guardian, etc.		E-mail Address

	Phone #	Address
PA-1G Revised 3/12				Page 1 of 8

SECTION III Marital Status Information

Name of Spouse:

Social Security #:

Birth Date:

Date of Marriage:

City/State where married:

Name of former Spouse (if applicable):

Social Security #:

Address:

County:

Date of Separation (if applicable):

Date of Divorce (if applicable):

Where divorced:

If Spouse is deceased, list date and city/state of death:

If applying for a child, list name of parents:

SECTION IV Living Arrangements

In order to calculate your benefit, we need information regarding your living arrangements.

If hospitalized / institutionalized, please complete this based on where you lived prior to entering the hospital or institution.

1. Do you: (Please check ALL boxes that apply.)
Own your own home?
Rent a	House?	Room?	Apartment?
	Is your name on the lease?			Yes No
Live in a residential health care facility?

Live in a licensed boarding home?

Live alone, or with your spouse? (If you live with children, please list them in #2 below.)

Live with a relative or friend?

Have other living arrangements not described above? Please explain:

Purchase and prepare your own meals?

Share your meals with others?

2.	List other people living with you. Include name, age, and relationship.

3.	How much is your household’s rent or mortgage?		What portion do you pay?

		Name and address of Mortgage Company or landlord:

SECTION V Earned and Unearned Income Information

Do you have income direct deposited to an account?

Yes


Employment:	List income for you, your spouse, or parent(s) (if applying for a child).
Please complete the following (including self-employment):		If not employed, check here

Person Employed

Name & Address of Employer

Gross Pay

Amounts

How Often Paid

(Weekly, Monthly, etc)

PA-1G Revised 3/12

Page 2 of 8

SECTION VI Benefits or Other Income

If you/your spouse/parent(s) with whom the applicant child lives, received, or have applied for income from any sources listed below, please complete all information that applies:

			Applied
			For/Have	If Benefit is	Name of
			Potential	If Benefit is	Name of
	Gross	How Often	To	Pending:	Recipient or	Claim # or
	Income	(Weekly/	Receive	Date of	Potential	Account # (if
Other Income	Received	Monthly)	(Yes/No)	Application	Recipient	applicable)

Social Security Benefits –

Including Retirement,

Disability or Survivor Benefits

Railroad Retirement

Supplemental Security

Income (SSI)

Pensions, including Private,

Government, Foreign

Annuities

Dividends, Royalties, Interest

Reparation Payments including German, Austrian, Other

Veterans Benefits / Military

Allotment or Pay

Unemployment Benefits /

Workers Compensation

Cash Public Assistance (TANF/GA)

Sick or Disability Payments

Payment from Boarders, Rent

Cash Support including

Child Support, Alimony

If anyone is helping to support you such as giving or loaning you money, list amount.

In Kind Support, including help with food, bills or shelter

Other Income (Non-Wages) including Strike or Black Lung Benefits

If you have no income or potential entitlement, check here

Lump Sum Income

If you received a Lump Sum Payment (including but not limited to winnings, gifts, inheritance, retroactive wages or benefits, etc.), indicate source, gross amount, and date received:

PA-1G Revised 3/12

Page 3 of 8

SECTION VII Resources

Using the following list, please check any resource owned by you, your spouse, and/or parent(s) (living with applicant child). These may be owned individually or jointly with others.

Cash on Hand		Real Estate, including but not limited to:
Cash that someone is holding for you		Home (principal residence)
Savings or checking accounts, or Certificate of Deposits		Home (other than principal residence)
Retirement savings plans – 401K, 403B, IRA, KEOGH		Investment property
Annuities, settlements, lottery winnings		Land
Stocks, bonds, or savings bonds		Other, including but not limited to jewelry,
		Other, including but not limited to jewelry,
Trust funds, including Special Needs Trusts	furs, coins, money or other valuables in safe
Credit Union or mutual fund shares	deposit box. Please indicate below:
Credit Union or mutual fund shares
Ownership of mortgages, notes, or contracts of value
Christmas / Vacation / Other Club savings accounts
Christmas / Vacation / Other Club savings accounts
Mineral / Natural Resource Interests
Mineral / Natural Resource Interests

None of the above

A. If you checked any resource above, please complete the following (if you need more room, use separate paper):

Bank Accounts owned or closed within the last 60 months

Bank Name

Bank Address

Name(s) on

Account

Account or Certificate #

Current

Value

If Closed, Date & Value at Closing

Investments (Stocks, Bonds, etc) owned within the last 60 months

Type of Investment

Company

Account #

Current

Value

If Closed, Date & Value at Closing

Property owned or sold within the last 60 months

Real Estate

(Include Type of

Property)

Address

Liens,

Mortgages, or Encumbrances

Fair

Market

Value

Owner(s)

If Sold, Date & Value at Sale

Is there a Plan of Liquidation on any of the above property?

Trusts

Yes

No (If yes, attach related form.)

Grantor:

Trustee:

Beneficiary:

Trust was funded by:

Own

Inheritance

Will

Other:

Tax ID #:

Date trust was initially funded:

PA-1G Revised 3/12

Page 4 of 8

SECTION VII Resources (Continued)
B. Burial Arrangements (if applicable)
Do you own any: (check all that apply)
Prepaid burial contracts/trusts irrevocable/revocable?		Value:
Funeral Home:
Burial plots?	Location:
Accounts set aside for burial (special bank account, etc.)?		Account #:	Value:

Have you or anyone set up a burial arrangement or contract that is paid through a life insurance policy?

Yes No Details:

C. Life Insurance Policies that you and/or Spouse own or for which you are the named insured:

Owner

Insured

Insurance Company

Policy #

Cash Value

Do you have any knowledge of being named beneficiary on someone else’s insurance policy?

Yes

No Details:

D. Vehicles owned by you, your spouse, parent(s)/stepparent(s) of applicant child living at home:

Include all types of transportation, such as cars, vans, tractors, pickup trucks, motor homes, motorcycles, boats, etc.

Owner’s Name

Year / Make

Model / Style

Use

Amount Owed

E. Transfers

Did you or your spouse trade, give away, or sell resources in which you had an interest, including but not limited to cash, real estate, vehicles, businesses, stocks, bank accounts, etc.?

Yes

No If yes, complete the information below for each transfer. Use additional paper if needed.


What was sold or given away?
By whom?			To whom?
Location (if land or property):
Date of sale or gift:			Amount received:

Did you retain a Life Estate?	Yes	No Date Recorded:

PA-1G Revised 3/12

Page 5 of 8

SECTION VII Resources (Continued)

F. Legal Issues

Are there any pending claims such as lawsuits, divorce settlements, inheritance, accident claims, sale of property, or

other claims? Yes No Details:


Attorney’s Name:			Phone #:
Address:
Does anyone owe you money?	Yes	No Details:

If there is a court order in effect to provide medical care or carry medical coverage, please indicate. For example: Is your absent parent or separated / divorced spouse under court order to provide medical care or carry medical coverage for you?

Is the disability, illness, or injury accident related?

Yes

No If yes, explain:

Will you be filing a lawsuit?

Yes

No Attorney Name:

Does anyone help you to pay for medical bills?

Yes

If yes, give the person’s name, amount of

payment and frequency. State if this is a loan, and if so, explain the terms of repayment agreement.

SECTION VIII Health Insurance Coverage

Please complete the following if you have coverage in your own name or have coverage under a spouse, parent, disability coverage, etc.

Also include other health care plans such as Medigap, Dental, Optical, and Prescription that may be available to pay for your/applicant health care needs.

Medical Insurance				Eligibility	Premium	Payment
Company Name &			Policy / Certificate	Eligibility	Premium	Payment
Address	Policy Holder	Coverage Type	Group or Claim #	Date	Amount	Frequency
		Part A
MEDICARE		Part B
		Part C

If you have Medicare coverage, are you also covered under Part D?

Yes

If you expect a change in insurance coverage, indicate. (Example: You, your parent or spouse recently started / left employment and will receive / drop coverage in a few months.)

If a change is expected, please give the carrier name, policy number, and date the insurance will go into effect / expires:

Yes

Is payment made directly to the Nursing Facility?

Yes

Do you have unpaid bills for medical services incurred within the past 3 months?

Yes

PA-1G Revised 3/12

Page 6 of 8

SECTION IX Rights and Responsibilities

Before signing this document, please read your rights and responsibilities outlined below.

If there is anything you do not understand or have questions about, please ask for clarification.

*The information I gave on this form is true to the best of my knowledge. I realize that if I knowingly give false information that isn’t true OR if I knowingly withhold information and I get health benefits for which I am not eligible, I can be criminally punished for fraud and I may have to pay Medicaid for any medical bills which are paid incorrectly.

*If I am a third party applying on behalf of another person, as evidenced by a completed Designation of Authorized Representative form, my signature below indicates 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 understand as a third party I may be criminally punished for knowingly providing false information.

*I understand that any information I give is subject to verification by the County Welfare Agency (CWA) and/or other agencies or officers of the NJ Department of Human Services, Division of Family Development (DFD) and the Division of Medical Assistance and Health Services (DMAHS). I understand that my medical benefits may be reduced, denied, or stopped because of information received.

*I hereby give permission to the CWA, DFD, and/or the DMAHS to contact any individual or other source who may have knowledge about my circumstances (including, but not limited to, IRS, Social Security Wage and Benefit files, State Wage and Unemployment files, and/or credit reporting services), for the sole purpose of verifying the statements I have made.

*I understand that Medicaid benefits received after age 55 may be reimbursable to the State of New Jersey from my estate.

*I agree to tell Medicaid immediately of the following changes:

1)If anyone receiving health benefits moves out of state;

2)Changes in where we live or get our mail;

3)Changes in other health insurance coverage;

4)Changes in income and/or resources;

5)Improvement in medical condition, if disabled;

6)Marriages and/or divorces;

7)Family members moving in or out of my household;

8)Sale of my home or other property;

9)Student status.

I understand that failure to do so may result in incorrectly paid benefits and I may have to reimburse the State of New Jersey for those benefits.

*I understand, as a condition of eligibility of medical assistance, that I have assigned to the Commissioner of Human Services, any rights to support for the purpose of medical care as determined by a court or administrative order and any rights to payment for medical care from any third party.

*I understand that I may request a fair hearing if I am not satisfied with any action taken regarding my application.

*I may be eligible for retroactive Medicaid coverage for unpaid covered medical services by Medicaid providers during the three (3) months prior to this application. I further understand that these retroactive benefits will only apply to the month(s) that eligibility requirements are met. This may be a separate form that must be completed within six (6) months from the date of this application.

PA-1G Revised 3/12

Page 7 of 8

SECTION IX Rights and Responsibilities (Continued)

*I understand that an individual is only permitted to retain $2,000 or $4,000 in applicable program resources in order to be eligible. If I am married and seeking nursing home care or a waiver program, the applicable program resource level will be higher. I understand that if I am seeking nursing home care or a waiver program, Medicaid will examine transfers of resources that occurred within the look back period before, and anytime after, my first date of applying for benefits.

*I give third parties permission to share information about me with authorized State and County staff conducting investigations pertaining to fraud, fraud prevention and misrepresentation. Third parties include, but are not limited to, financial institutions, credit reporting agencies, landlords, public housing agencies, schools, utility companies, insurance agencies, employers, other governmental agencies and others as they apply. I further authorize taxing authorities to release copies of my income tax returns. I also understand that my permission for release is effective for six (6) months after my benefits stop.

*I understand that I will not be discriminated against because of race, color, religion, sex, handicap, national origin, or marital, parental, or birth status. To file a complaint of discrimination, I should contact the U.S. Department of Health and Human Services (HHS) in writing to the HHS Director, Office of Civil Rights, Room 506F, 200 Independence Avenue, SW, Washington, DC 20201 or call 202-619-0403 (voice) or 202-619-3257 (TDD). HHS is an equal opportunity provider and employer.

*I understand that by accepting Medicaid, I give DMAHS the right to any medical support or payments from third parties who would be legally responsible for any medical services paid by Medicaid for me or any member of my household. I agree to release any medical information needed by the Medicaid Program or others for the purpose of paying or receiving payment of medical bills. I understand that this is required to get coverage. I agree to help in obtaining medical support and payments from anyone who is legally responsible.

*I, by signing below, attest that I have read and agree to these statements and fully realize that the CWA and/or DFD and/or DMAHS rely upon the truth and accuracy of my statements.

I, (print name), have read or had read to me the statements on this

page. I understand those statements. Upon penalty of perjury, I swear that the answers I have given on this application are complete and correct. I am the person represented by the signature on this document.

Applicant Signature

Date

Authorized Agent Signature

Date

Relationship to Applicant

Address

Witness

Date

NOTE: The submission of a Social Security number (SSN) is mandatory in accordance with 42 U.S.C. 1320b-7.

Your SSN will be used to check your identity, prevent duplicate participation, and facilitate making mass changes. Your SSN will also be used in computer matching and program reviews or audits and to make sure you are eligible for Medicaid. These procedures are designed to identify persons who fraudulently or wrongfully participate in the Medicaid programs. Such persons may be subjected to criminal action, administrative claims, and/or possible loss of all benefits. Failure to file for a SSN may result in disqualification for Medicaid.

PA-1G Revised 3/12

Page 8 of 8

How to Edit Nj Pa 1G Form Online for Free

medicaid forms nj can be completed without any problem. Just make use of FormsPal PDF editor to do the job in a timely fashion. We at FormsPal are dedicated to making sure you have the best possible experience with our tool by consistently releasing new features and improvements. With these updates, working with our tool becomes better than ever before! It just takes a couple of simple steps:

Step 1: Press the "Get Form" button above. It will open up our editor so that you can begin completing your form.

Step 2: This editor allows you to customize PDF documents in a range of ways. Modify it with your own text, correct original content, and include a signature - all readily available!

This PDF form will require specific data to be typed in, so you must take your time to fill in what's asked:

1. It's vital to complete the medicaid forms nj accurately, thus take care while filling out the segments comprising these specific blank fields:

Tips to fill out nj medicaid application online stage 1

2. After filling in this section, head on to the subsequent stage and fill out all required particulars in all these fields - Male, Female Marital Status, This is a legal document and, If no explain citizenship status, CityTown, No Date applied for, Zip, State, VA if known, If yes why, Widowed, Child, Alien, Single, and Married.

State, This is a legal document and, and Zip in nj medicaid application online

3. This third part is relatively uncomplicated, Signature of Person Initiating, Relationship to Applicant Parent, Address, Date, Email Address, PAG Revised, and Page of - all of these fields has to be filled out here.

nj medicaid application online writing process described (portion 3)

People who work with this PDF often make errors while filling in Email Address in this area. Ensure you go over everything you enter here.

4. Completing SECTION III Marital Status, Name of Spouse, Date of Marriage, Social Security, Birth Date, CityState where married, Name of former Spouse if applicable, Address, Date of Separation if applicable, Social Security, County, Date of Divorce if applicable, Where divorced, If Spouse is deceased list date, and If applying for a child list name is key in the fourth stage - always take the time and take a close look at each and every empty field!

Stage # 4 of filling out nj medicaid application online

5. The document should be wrapped up within this part. Below there can be found a comprehensive list of fields that need specific details for your form submission to be accomplished: Is your name on the lease Live in, Yes, Live in a licensed boarding home, Live with a relative or friend, Share your meals with others, List other people living with you, Name and address of Mortgage, What portion do you pay, SECTION V, Earned and Unearned Income, Do you have income direct, and Yes.

Completing part 5 in nj medicaid application online

Step 3: After looking through your entries, click "Done" and you're good to go! Join us now and instantly access medicaid forms nj, ready for downloading. All modifications made by you are saved , letting you edit the form further when necessary. FormsPal provides safe document editor without personal information record-keeping or sharing. Feel at ease knowing that your information is in good hands here!

Do you have Long-Term Care (LTC) Insurance?

No If yes, complete below:

Insurance Company Name:

Is it a LTC Partnership Policy?

Amount of benefit:

How much of the benefit have you used?