Pa 600 L Sg Form – Fill Out and Use This PDF

The Pa 600 L Sg Form is a powerful document created to serve many purposes. This legal document allows substantial authority in majority situations, and is applicable by any resident living within the boundaries of the area in which it applies. From inventories to arbitration agreements, the Pa 600 L Sg Form covers comprehensive and varied issues that require professional attention. Its procedural regulations guarantee only valid results, providing those deemed lawfully bound to such documents an assurance of due commitment. Beyond all doubt, the complete validation status inherent gives individuals reason to trust their judgement in leveraging this form. It also enables correct collection and timely application of every clause necessary for its legality—a ground for reliable exchanges for purposes like inclusion in contracts and situation specific resolutions dually noted in public records. Ultimately, the Pa 600 L Sg form promises first class fairness and accuracy by acts awarded from parties fully informed on what makes up the agreement at hand.

Pa 600 L Sg Form PDF Details

Are you a business or organization looking for an efficient way to manage and submit reports? Filing the Pa 600 L Sg form could be your solution. This document is used to report information related to the retention of security deposits from tenants by landlords. It is loaded with important rules and regulations that must be followed, making it essential for businesses and organizations involved in real estate rental transactions to understand the details associated with this form. We will provide an overview of what you need to know about filing the Pa 600 L Sg form accurately and efficiently.

Question	Answer
Form Name	Pa 600 L Sg Form
Form Length	11 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	2 min 45 sec
Other names	00 08 04_attch08_pa600LS G_medicaid_elig pa 600 l sg 2006 form

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

E. Automobiles, recreational Vehicles, Trucks, Motorcycles None

NAME OF OWNER(S)

YEAR

MAKE

MODEL

LICENSED?	PLATE NUMBER

ACCOUNT

F. bank Accounts (Checking, Savings, irA, etc.) List all accounts that include applicant’s and/or spouse’s name and money. None

BANK NAME/BRANCH

ACCOUNT TYPE

ACCOUNT NUMBER

CURRENT BALANCE

NAME(S) ON ACCOUNT/OWNER

g. Stocks, bonds (including u.S. Savings bonds), Trusts, Mutual Funds, cash on hand, etc. None

NAME ON INVESTMENT

TYPE ACCOUNT

ACCOUNT NUMBER	CURRENT ACCOUNT VALUE

NAME(S) ON ACCOUNT/OWNER

10	within the past 60 months, have you or your spouse closed, given away, sold or transferred any assets such as: a home, land, personal
	property, life insurance policies, annuities, bank accounts, certificates of deposit, stocks, irA, bonds or a right to income?	Yes	No

within the past 60 months, have you or your spouse transferred any assets into a trust?

Yes

If yes to either question, explain circumstances (attach extra paper if needed)_______________________________________________________________________________

_____________________________________________________________________________________________________________________________________________

TYPE OF RESOURCE(S)

MARKET VALUE

AT TIME

OF TRANSFER

DATE OF TRANSFER

OR CLOSING

6	PA 600 L (SG) 8/12

11 if you closed or depleted any accounts because you paid for nursing services, list these accounts.

TYPE OF RESOURCE

LOCATION

ACCOUNT NUMBER

OWNER(S)

DATE OF CLOSING

12	have you or your spouse received or does either of you expect to receive any income/asset/settlement/lump sum/inheritance?		Yes
If yes, describe:		AMOUNT $
		DATE EXPECTED

13 income information for the applicant:

INCOME SOURCES

SOCIAL SECURITY

VETERANS BENEFIT AID AND ATTENDANCE

PENSIONS

WORKER’S COMPENSATION

RAILROAD RETIREMENT

BLACK LUNG

ANNUITY (COMPANY)

PAYMENTS FROM A TRUST

INTEREST/DIVIDEND (SOURCE)

OTHER INCOME

	TO WHOM ARE THE	s
	CHECKS SENT? (GUARDIAN,	s
	CHECKS SENT? (GUARDIAN,
	REPRESENTATIVE PAYEE)

IDENTIFY INVESTMENT TYPE/NAME	GROSS INCOME AMOUNT	HOW OFTEN PAID
______________________________________	_________________________	____________________
______________________________________	_________________________	____________________
______________________________________	_________________________	____________________
______________________________________	_________________________	____________________
______________________________________	_________________________	____________________
______________________________________	_________________________	____________________
______________________________________	_________________________	____________________
______________________________________	_________________________	____________________
______________________________________	_________________________	____________________
______________________________________	_________________________	____________________
	ADDRESS
	ADDRESS

7	PA 600 L (SG) 8/12

Complete this section if you have a spouse or dependent. Skip this section if you are not married or do not have a dependent.

14 income information for the spouse and/or dependent:

INCOME SOURCES	IDENTIFY INVESTMENT TYPE/NAME	GROSS INCOME AMOUNT	HOW OFTEN PAID
SOCIAL SECURITY	______________________________________	_________________________	____________________
VETERANS BENEFIT AID AND ATTENDANCE	______________________________________	_________________________	____________________
PENSIONS	______________________________________	_________________________	____________________
WORKER’S COMPENSATION	______________________________________	_________________________	____________________
RAILROAD RETIREMENT	______________________________________	_________________________	____________________
BLACK LUNG	______________________________________	_________________________	____________________
ANNUITY (COMPANY)	______________________________________	_________________________	____________________
PAYMENTS FROM A TRUST	______________________________________	_________________________	____________________
INTEREST/DIVIDEND (SOURCE)	______________________________________	_________________________	____________________
OTHER INCOME	______________________________________	_________________________	____________________

15 Shelter expense:

MONTHLY RENT/MORTGAGE	$ _____________________		BASIC TELEPHONE	$_______________________
SALES OR LEASE PURCHASE AGREEMENT	$ _____________________		GAS	$_______________________
PERSONAL CARE OR DOMICILIARY CARE RENTAL CHARGE	$ _____________________		ELECTRIC	$_______________________
MAINTENANCE CHARGES FOR CONDO OR CO-OP RESIDENCE	$ _____________________		HEATING FUEL	$_______________________
LOT RENT FOR MOBILE HOME	$ _____________________		WATER	$_______________________
PROPERTY TAXES - ANNUAL AMOUNT	$ _____________________		SEWER	$_______________________
HOMEOWNERS INSURANCE - ANNUAL AMOUNT	$ _____________________		GARBAGE	$_______________________
Do you pay for heating and/or air conditioning separate from your rent?	Yes	No

8	PA 600 L (SG) 8/12

righT To nondiSCriMinATion

We may not discriminate on the basis of age, sex, race, color, ancestry, disability, religious creed, national origin, sexual preference, life-style, union membership, political belief, or because you applied for and/or received assistance before. If you feel you have been discriminated against by the Department or anyone providing services for the Department, you may file

a verbal or written complaint with the Department or the county assistance office. The Department or county assistance office will then forward the complaint to the appropriate Federal or State agency.

righT To APPEAL

You have the right to ask for a Departmental hearing to appeal a decision of or failure to act by the Department which affects your benefits or that you feel is unfair or incorrect. You may file the appeal at the county assistance office. At the appeal hearing, you may represent yourself or someone else, such as a lawyer, friend, or a relative may represent you.

righT To An AgEnCY ConFErEnCE

If you appeal, you may have an agency conference before the hearing.

righT To A wriTTEn noTiCE

We will give you a written notice explaining your benefits. If we deny, change, suspend, or stop benefits, we will explain the reason on the notice. You have 30 days from the date of the notice to ask for a hearing if you disagree with the action taken and/or the reasons given.

righT To ConFidEnTiALiTY

We keep information you give confidential and use it only to administer the programs you apply for and may be eligible for. Any person knowingly violating any of the rules and regulations of this Department made in accordance with this article shall be guilty of a misdemeanor, and upon conviction thereof, shall be sentenced to pay a fine, not exceeding one hundred dollars ($100), or to undergo imprisonment, not exceeding six months, or both (62 P.S. Section 483).

ESTATE rECoVErY

If you are age 55 or older and receive medical assistance to pay for nursing facility services, home and community-based waiver services and any related hospital and prescription drug service, you will be required to repay the cost of these services from your probate estate. You may call the MA Estate Recovery Program at 800-528-3708.

ChAngES

If you are not sure if you must report a particular change, you should report the change. You can report to a member of the county assistance office staff in person, by telephone, or by mail.

uSE oF ThE PA ACCESS CArd

You may use the PA ACCESS card for services only during the period you are eligible. You must use the card only for the person who is eligible and you may get only services that are needed and reasonable.

rESPonSibiLiTY To ProVidE SSns

You must provide a Social Security Number (SSN). If you do not have an SSN, you must apply for one. Refusal or failure to provide an SSN may result in disqualification. If you have a community spouse, he or she must also supply an SSN. We use the SSN to verify identity, administer our programs, prevent duplication in state and federal programs, for computer matches with other programs, and to get information about income and resources to determine eligibility for and/or the amount of your benefits (42 U.S.C. Section 1320b-7).

PEnALTiES

If you do not report changes as required, your benefits may be reduced or stopped. If you purposely fail to give correct information or report changes, you may be fined and/or put in jail. Improper use of the PA Access Card for services may result in a fine, imprisonment or both.

rESPonSibiLiTY To ProVidE inForMATion You must give true, correct and complete information to the best of your ability. You must cooperate in documenting or verifying the information. If you cannot provide proof, you should ask the county assistance office to help. You must cooperate fully with quality control and with persons from the Department or

the Inspector General’s Office who are conducting investigations.

I UNDERSTAND:

My benefits may be reduced or I can be penalized for giving incomplete or false information or for not reporting changes that would affect my benefits.

Any person enriched as a result of a transfer of assets or income, which would have affected my eligibility, will be liable for repayment of those benefits issued incorrectly.

I am giving the state the right to seek, with or without legal action, payment from private or public health insurance or liable third party. The amount recovered will not exceed the amount paid by Medical Assistance.

The state has the right to review all records of medical service paid for by Medical Assistance.

Payment for medical services will be made directly to the provider, not to me. This includes payments from Medicare.

I received a copy of my rights and responsibilities, have read them or someone has read them to me, and I understand them.

I agree to provide or cooperate in getting any information needed to prove my statements.

I must report any changes in my circumstances within 10 days of the change.

I am responsible for any fraudulent statements made on this application even if the application is submitted by someone acting on my behalf.

The state operates a fraud control program under which local, state, and federal officials may verify the information I have given.

The state may obtain information about my circumstances from other persons or organizations, including computer matches and Immigration and Naturalization.

My Social Security Number will be used to obtain information to verify my circumstances and eligibility.

9	PA 600 L (SG) 8/12

AFFidAViT

I certify, subject to penalties provided by law, that the information I gave is true and correct and complete to the best of my knowledge.

I have read this application in full or someone has read it to me and I understand the questions asked. I have received a copy of and read my rights and responsibilities, or someone has read them to me, and I understand them.

APPLICANT OR AUTHORIZED REPRESENTATIVE SIGNATUREDATE I.D. VERIFIEDRELATIONSHIP TO APPLICANT

(

)

ADDRESS OF REPRESENTATIVE

CITY

STATE

ZIP CODE + 4

TELEPHONE NUMBER

WITNESS (IF SIGNED WITH AN X ABOVE)

DATE

(

)

ADDRESS OF WITNESS

CITY

STATE

ZIP CODE + 4

TELEPHONE NUMBER

PROVIDER SIGNATURE (IF SUBMITTED BY PROVIDER)

DATE

Face to Face Interview With

CAO OR OPTIONS

DATE

Telephone Interview With

Interview Waived

who is your representative or power of attorney?

Copies of notices will be sent to the person named.

LAST NAME, FIRST NAME, MIDDLE INITIAL

RELATIONSHIP TO APPLICANT

REPRESENTATIVE POWER OF ATTORNEY

ADDRESS

CITY

STATE

ZIP CODE + 4

TELEPHONE NUMBER

()

i wiSh To wiThdrAw MY APPLiCATion

/ /

SIGNATURE

DATE

10	PA 600 L (SG) 8/12