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) Authorization for the Department to Release Information (indicate the Facility name or Facility staff that DHS can discuss information with) Any available resource and income verifications that are currently available (these will be requested by a DHS worker if not provided with the Application ) VA release of information (if currently receiving benefits from the VA)

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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