Pa Form 1572 PDF Details

Understanding the paperwork involved in opening a clinical laboratory can be overwhelming, but every step is essential for providing accurate and reliable results. To help simplify the process, we’ve broken down the important form 1572—known as Statement of Investigator(s)– and discussed what it is, who needs to complete it, when it must be completed by and any required attachments. This post focuses on giving you all of the information you need to successfully complete Pa Form 1572 so that you can feel confident managing your clinical lab with ease!

QuestionAnswer
Form NamePa Form 1572
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namespa1572, pennsylvania resource assessment form, pa 1572 from, pa 1572 resource form

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PART 4

Instructions for Completing Resource Assessment Form, PA 1572

(To be used by a couple when one of them is in a nursing facility, other medical institution or assessed

eligible for Home and Community Based Services (HCBS), and the other lives in the community.)

Important information for nursing facility residents and their spouses. If you need this information in another language or someone to interpret it, please notify the nursing facility or contact your local County Assistance Office. Language assistance will be provided free of charge.

Información importante para los residentes en hogares de ancianos y sus esposos. Si usted necesita esta información en otro idioma o alguien que se la traduzca, favor de notificar al personal de la residencia o comunicarse con la oficina local de Asistencia del Condado (CAO). Asistencia lingüística será proveída gratis.

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这是发给疗养所的居民及其配偶的重要通知。如果您需要此通

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您所在地区的郡县协助办事处(County Assistance Office)。可提

供免费语言协助。

The Medical Assistance Program - known as MA - helps meet the medical costs of individuals in need of payment of Long Term Care (LTC) services. Generally, an individual must use most of his own resources and income before Medical Assistance will help pay for LTC services. There are, however, special rules (sometimes called the Spousal Impoverishment Provisions) which recognize the importance of pro- tecting a portion of a married couple’s total resources and evaluating the income needs of the spouse who remains in the community.

The purpose of this Resource Assessment Form is to determine how much of a married couple’s total resources may be protected or set aside for the community spouse, and how much, if any, must be spent before the individual in the nursing facility or assessed eligible for HCBS may be eligible for Medical Assistance benefits. Completing this form will help you to protect the maximum amount of your resources under the law.

The Resource Assessment is not an application for Medical Assistance, and you are not obligated to apply for Medical Assistance. If you need help in com­ pleting this form, your spouse, family member, friend, attorney, or legal services agency can help you. If you or your spouse are over 60 years of age, your local Area Agency on Aging also can help you. If you need Medical Assistance now, contact your county assistance office or your local Area Agency on Aging BEFORE you fill out this form.

A community spouse may keep a minimum amount of resources, or one-half of the couple’s combined countable resources, up to a maximum amount. Some resources do not affect the determination of the protected amount. In order to make the determination as to which resources do and do not count and the protected amount, it is very important that you list all resources regardless of whether they are wholly owned by one person (e.g., an IRA owned by the community spouse), are owned by both spouses, or owned with others. The information on this form should reflect the value of the resources as of the DATE OF ADMISSION to the nursing facility, or the DATE OF ASSESSMENT for HCBS, NOT the date you fill out this form.

Photocopies verifying all resources MUST be sent with this form. Do not send original documents as they will NOT be returned to you. An assessment cannot be com- pletedunlessallresourcesareverifiedandtheverificationis submitted with the Resource Assessment Form.

Please read and complete this form carefully. Do NOT complete shaded areas. Sign the form and review the checklist to be certain you have provided all necessary verification. You, your spouse, and if applicable, your legal representative, will be notified in writing of the amount of resources that can be set aside and the amount, if any, that must be spent before you apply for Medical Assistance.

Mail (or deliver) the completed form and verification to the county assistance office in the county where the nursing facility is located, or you are receiving HCBS. The LTC Service Provider can provide you with the address, or check the telephone book.

-1-

PA 1572 2/11

RESOURCES/ACCEPTABLE PROOF

VERIFICATION OF ALL RESOURCES MUST BE ATTACHED TO THE FORM. FOR EXAMPLE:

CODE

RESOURCE

VERIFICATION

*Value as of date of admission to nursing facility or date of assessment for home and community based services (HCBS).

 

 

 

01

CASH ON HAND

Your written statement showing the total amount of money not in the bank or

 

 

otherwise invested.

 

 

 

02

SAVINGS ACCOUNT(S)

Photocopies of your bank statements, bank books or a written statement from the

 

 

financial institution.*

 

 

 

03

CHECKING ACCOUNT(S)

Photocopies of your bank statement or written statement from the

 

 

financial institution.*

 

 

 

04

CHRISTMAS AND/OR

Photocopies of the bank statement or written statement from the financial institution.*

 

VACATION CLUB

 

05

STOCKS AND/OR BONDS, ETC.

A written statement from the brokerage firm, issuing agent or authority or institution where the

 

 

stocks, bonds, etc. were purchased or held; or copy of the stock certificate or bond and a

 

 

statement of the value.*

 

 

 

06

TRUST FUND

Photocopy of the trust agreement and inventory of trust assets or other documentation

 

 

of value.*

07

IRREVOCABLE BURIAL RESERVE

Photocopy of the burial reserve agreement.

 

 

 

08

REVOCABLE BURIAL RESERVE

Photocopy of the burial reserve agreement.

 

 

 

09

RESERVED

 

10

LIFE INSURANCE

A document identifying ownership for each insurance policy and a written statement of cash

 

 

value from the insurance company.*

 

 

 

11

NON-RESIDENT REAL

Your real estate tax bill or a broker’s statement of the fair market value of the property; and

 

PROPERTY

if the property is rented, the rental agreement or lease.*

 

 

 

12

MOTOR VEHICLE(S)

A written statement of the value, from a car dealer; or list the year, make, and model of the

 

 

vehicle, and we will use the automobile red book to determine the value.

13

BOATS, SNOWMOBILES,

A written statement of the fair market value of the vehicle, from a dealer.*

 

TRAILERS AND OTHER VEHICLES

 

 

 

 

14

CERTIFICATES OF DEPOSIT

A written statement from the financial institution listing the value and ownership.*

15

ANNUITIES

A photocopy of the document that explains the terms, date of purchase, and value of the annuity

 

 

at the time of admission/or assessment for HCBS.*

 

 

 

16

SAVINGS BONDS

Photocopies of the bonds or a written statement from a bank that identifies the owner(s) of the

 

 

bonds, the serial number(s), purchase date, and the value of the bonds at the time of

 

 

admission.*

 

 

 

17

MUTUAL FUNDS

An itemized written statement of the value from the mutual fund or brokerage firm.*

 

 

 

18

INCORPORATED OR

For a corporation, a statement of the value of your stock; for an unincorporated business,

 

UNINCORPORATED BUSINESS

documents that established the business and that verify the value of your share of the business.

 

(PARTNERSHIP/SOLE PROPRIETORSHIP)

 

 

 

 

19

IRA OR KEOGH

A written statement from the bank or financial institution that identifies the owner(s) and the

 

 

value.*

 

 

 

20

OTHER

Photocopy(ies) of any agreement(s) or statement(s) regarding any money or other resources

 

 

not already listed.*

 

 

 

PA 1572 2/11

-2-

COMMONWEALTH OF PENNSYLVANIA - DEPARTMENT OF PUBLIC WELFARE

RESOURCE ASSESSMENT

YOUR INFORMATION IS CONFIDENTIAL FOR USE ONLY BY THE DEPARTMENT OF PUBLIC WELFARE

GENERAL INFORMATION

 

 

 

 

 

 

 

 

 

 

LAST NAME

FIRST NAME

M.I.

 

DATE OF BIRTH

 

SOCIAL SECURITY NO.

 

 

 

 

/

/

 

 

 

 

ADDRESS

(STREET AND CITY)

 

 

COUNTY

 

STATE

 

ZIP CODE

 

 

 

 

 

 

 

 

 

NAME OF LTC SERVICE PROVIDER

 

 

 

TELEPHONE NO.

 

DATE OF ADMISSION OR

 

 

 

(

)

 

 

 

HCBS ASSESSMENT

 

 

 

 

 

 

/

/

SPOUSE’S LAST NAME

FIRST NAME

M.I.

 

DATE OF BIRTH

 

SOCIAL SECURITY NO.

 

 

 

 

/

/

 

 

 

 

SPOUSE’S STREET ADDRESS

CITY

 

STATE

 

ZIP CODE

 

SPOUSE’S TELEPHONE NO.

 

 

 

 

 

 

 

(

)

 

 

 

 

 

 

 

 

 

 

 

 

 

RESOURCES

VERIFICATIONMUSTACCOMPANYTHISFORMFOREACHRESOURCELISTED.ACCEPTABLEVERIFICATION AND CORRESPONDING RESOURCE CODES ARE LISTED ON THE BACK OF THE INSTRUCTION PAGE.

DO NOT SEND ORIGINAL DOCUMENTS, AS VERIFICATIONS WILL NOT BE RETURNED. If a resource is owned by you and another person other than your spouse, list on a separate sheet of paper the resource and the names of the joint owners. Indicate if you or someone else purchased the asset. If it is not owned in equal shares, provide proof of the division of ownership as well as total value.*

BE CERTAIN TO LIST ALL RESOURCES, SINGLY OR JOINTLY-OWNED

 

 

OWNER(S) OF RESOURCE

RESOURCE

 

*As of the date of admission or HCBS assessment.

DOCUMENTED

LAST NAME

FIRST NAME

 

M.I.

CODE

TOTAL VALUE

AMOUNT OWED

 

NET VALUE

YES

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

IF YOU NEED ADDITIONAL SPACE, USE NOTES/INFORMATION SECTION OF THE FORM

 

 

 

 

 

 

 

 

NOTE: IF YOUR INTEREST IN ANY RESOURCE IS A LIFE INTEREST, PLEASE INDICATE

 

 

 

 

 

 

 

ENTER THE TWO DIGIT CODE IN THE “RESOURCE CODE” COLUMN THAT BEST DESCRIBES THE RESOURCE THAT YOU ARE IDENTIFYING

 

 

 

01

CASH ON HAND

 

07

IRREVOCABLE BURIAL RESERVE

13

BOATS, SNOWMOBILES,

18

BUSINESS

 

 

 

02

SAVINGS ACCOUNT(S)

08

REVOCABLE BURIAL RESERVE

 

TRAILERS & OTHER VEHICLES

19

IRA OR KEOGH

03

CHECKING ACCOUNT(S)

09

RESERVED

 

14

CERTIFICATES OF DEPOSIT

20

OTHER

 

 

 

04

CHRISTMAS/VACATION CLUB

10

LIFE INSURANCE

 

15

ANNUITIES

 

 

 

 

 

05

STOCKS, BONDS, ETC.

11

NON-RESIDENT REAL ESTATE

16

SAVINGS BONDS

 

 

 

 

 

06

TRUST FUND

 

12

MOTOR VEHICLE(S)

17

MUTUAL FUNDS

 

 

 

 

 

-3-

PA 1572 2/11

LIFE INSURANCE - COMPLETE THE INFORMATION BELOW FOR EACH LIFE INSURANCE POLICY

NAME OF INSURED

INSURANCE

POLICY

NAME OF

FACE

COMPANY

NUMBER

BENEFICIARY

VALUE

 

 

 

 

CASH*

DATE

DOCUMENTED

VALUE

ACQUIRED

YES

NO

 

 

 

 

*As of the date of admission to the facility or assessment for HCBS.

NOTES/INFORMATION SECTION -- USE ADDITIONAL SHEET(S) IF NECESSARY

LIST ANY PRIOR ADMISSION TO A FACILITY OR ASSESSMENT FOR HCBS

NAME AND

＠

ADDRESS OF

 

LTC SERVICE PROVIDER

DATE OF ADMISSION OR ＠ ASSESSMENT FOR HCBS

NAME AND

＠

ADDRESS OF

 

LTC SERVICE PROVIDER

DATE OF ADMISSION OR ＠ ASSESSMENT FOR HCBS

LEGAL REPRESENTATION

ﾅYES ﾅNO

DOES THE INDIVIDUAL HAVE A LEGAL REPRESENTATIVE OTHER THAN THE SPOUSE

(e.g. Court-appointed Guardian, Power-of-Attorney, etc.)

IF ＠

YES

NAME

 

TELEPHONE

 

 

 

 

 

 

NUMBER

 

 

 

 

 

 

STREET ADDRESS

CITY

STATE

ZIP CODE

RELATIONSHIP OF RESIDENT

 

 

 

 

 

NOTE: YOUR LEGAL REPRESENTATIVE WILL BE SENT A COPY OF THE RESULTS OF THE RESOURCE ASSESSMENT.

I swear or affirm that all of the information I have provided on this form is true and correct to the best of my ability, knowledge and belief.

SIGNATURE

DATE

RELATIONSHIP TO INDIVIDUAL IN NEED OF LTC SERVICE

CHECKLIST

1.DID YOU COMPLETE THE INFORMATION FOR THE INDIVIDUAL IN NEED OF LTC SERVICES?

2.DID YOU COMPLETE THE INFORMATION FOR THE COMMUNITY SPOUSE?

3.DID YOU LIST ALL RESOURCES OWNED ON THE DATE OF ADMISSION OR ASSESSMENT FOR HCBS?

4.DID YOU COMPLETE THE LIFE INSURANCE SECTION?

5.DID YOU READ THE STATEMENT REGARDING THE INFORMATION YOU PROVIDED? DID YOU SIGN THE FORM, INDICATE YOUR RELATIONSHIP TO THE INDIVIDUAL IN NEED OF LTC SERVICES AND DATE THE FORM?

6.DID YOU ATTACH PHOTOCOPIES OF THE DOCUMENTATION TO VERIFY YOUR RESOURCES?

FOR DPW USE ONLY

TOTAL VERIFIED COUNTABLE RESOURCES

 

 

 

$ __________________

 

 

 

 

 

 

 

 

 

 

 

 

 

SPOUSE’S SHARE 1/2 TOTAL NET VERIFIED RESOURCES

$ __________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

ASSESSOR’S SIGNATURE

 

 

DATE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

NOTICE

＠

INDIVIDUAL RECEIVING LTC

 

 

 

 

 

 

 

LEGAL

 

 

 

 

 

 

SENT TO

SERVICES

 

YES

 

NO

SPOUSE

 

YES

 

NO

REPRESENTATIVE

 

 

 

YES

 

NO

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PA 1572 2/11

-4-

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