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Application Checklist for Facility Medicaid - …

1 Application Checklist for Facility Medicaid The following items are needed for Application processing. Health Services Application Form #470-2927 or Application for Health Coverage and Help Paying Costs, Form #470-5170 Facility Assistance Questionnaire Worksheet Insurance Questionnaire, Form #470-282 (if applicable) Copy of Medicare Card (if applicable) POA Documentation (if applicable) Resources Upon Entering a Medical Facility , Form #470-2577 (if married and no prior attribution) Case Activity Report, Form #470-0042 (send at time of Application ) Level of Care assessment to IME, Form #470-4393 (send to IME as soon as completed)

1 Application Checklist for Facility Medicaid The following items are needed for application processing. ☐Health Services Application Form #470-2927 or Application for Health Coverage

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