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DHS-4574, Application for Health Care Coverage …

DHS-4574 (Rev. 5-16) Previous edition FOR Health CARE Coverage PATIENT OF NURSING FACILITYM ichigan Department of Health and Human ServicesFOR OFFICE USE ONLYB eneficiary NameClient IDCase NumberHELP IS AVAILABLEC ountyDistrictSectionUnitSpecialistThe Michigan Department of Health and Human Services must help all persons fill out the Application , when requested. If you need help, please call or visit your specialist or the office named below. If you need an interpreter, the Department will provide one free of charge or you may use one of your choice.

DHS-57 (Rev. 5-16) Previous edition obsolete. APPLICATION FOR HEALTH CARE COVERAGE PATIENT OF NURSING FACILITY Michigan Department of …

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Transcription of DHS-4574, Application for Health Care Coverage …

1 DHS-4574 (Rev. 5-16) Previous edition FOR Health CARE Coverage PATIENT OF NURSING FACILITYM ichigan Department of Health and Human ServicesFOR OFFICE USE ONLYB eneficiary NameClient IDCase NumberHELP IS AVAILABLEC ountyDistrictSectionUnitSpecialistThe Michigan Department of Health and Human Services must help all persons fill out the Application , when requested. If you need help, please call or visit your specialist or the office named below. If you need an interpreter, the Department will provide one free of charge or you may use one of your choice.

2 If you are refused help in filling out the Application , call 855-275-6424 or you need the Department to provide an interpreter to help you at the interview? c Yes c NoIf yes, what language? _____El Michigan Department of Health and Human Services (MDHHS) no discrimina contra ning n individuo o grupo a causa de su raza, religi n, edad, origen nacional, color de piel, estatura, peso, estado matrimonial, informaci n gen tica, sexo, orientaci n sexual, identidad de sexo o expresi n, creencias pol ticas o READ CAREFULLYFOR NURSING FACILITY patients ONLYC omplete this form if you are in a nursing facility.

3 Please read each item carefully before you answer it. The answers you give will be used to determine if you are eligible for Health care Coverage . Be sure to sign your name on pages 2 and can apply for Health care Coverage by mailing or having someone take this form into your local Michigan Department of Health and Human Services (MDHHS) office. Your Application must be approved or denied within: 45 days, or 90 days if disability is a factor in determining your Health care Coverage DCH-1426, Application for Health Coverage and Help Paying Costs, if other family members want help with medical Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.

4 LOCAL OFFICE:AUTHORITY:COMPLETION:PENALTY:42 CFR PART Healthcare Michigan Department of Health and Human Services debe ayudar a todas las personas a completar la aplicacion cuando asi lo piden. Si usted necesita ayuda, por favor llame o visite a su especialist o la oficina el nombre debajo. Si necesita un interprete, el departmeto le proporcionar uno gratis o usted puede usar uno de su eleccion. Si usted es negado ayuda para completar la aplicacion, puede llamar al 855-275-6424 o 855-789-5610. Necesita que el Departamento proporcione un interprete para que le ayude en la entrevista?

5 C si c noSi dice que si, en que idioma? _____ .. : 6424-275-855 5610-789-855.. _____ DHS-4574 (Rev. 5-16) Previous edition OFFICE USE ONLYNOTESDHS-4574 (Rev. 5-16) Previous edition OFFICE USE ONLYNOTESDHS-4574 (Rev. 5-16) Previous edition OFFICE USE ONLYNOTESDHS-4574-B (Rev. 5-16) Previous edition obsolete. 1 ASSETS DECLARATIONPATIENT AND SPOUSEM ichigan Department of Health and Human Services(Skip if no spouse)FOR OFFICE USE ONLYB eneficiary NameClient IDCase NumberCountyDistrictSectionUnitSpecialis tPLEASE PRINTP atient s Name (First, Middle, Last)Phone No.

6 Of Nursing HomeSpouse s Name (First, Middle, Last)Spouse s Phone of Nursing Home (Number, Street, Rural Route)Spouse s Address (Number, Street, Rural Route)CityStateZip CodeCityStateZip CodePatient s Birthdate (Mo/Day/Yr)Patient s Social SecuritySpouse s Birthdate (Mo/Day/YrSpouse s Social Security*This form asks questions about the property or assets owned by you and/or your spouse. This information is needed to determine your eligibility for Healthcare Coverage and the amount of assets that can be protected for the benefit of your spouse.)

7 Answer the following questions by providing information about all assets owned by you and/or your spouse as of _____. Include assets you or your spouse own jointly with family or other Do you and/or your spouse have any assets (include assets held jointly)?c Ye s4 Check all types of assets your household has and complete the tablec Noc Checking/draft accountc Money market accountsc Savings/share accountsc Certificates of Deposit (CD)c Christmas club accountsc Patient trust fundc Case on hand or in safe depositc Savings, bonds, stocks or mutual fundsc IRA, KEOGH, 401K or DeferredCompensation account(s)c Trust or Annuityc Land contract, mortgage or othernotes payable to household memberc Real estate (including place you live)c Life estate/life leasec Burial plot(s)

8 , casket, Tools, equipment, livestock or cropsc Life insurancec Other Assets _____c Health Savings Accountc Burial trust/funeral contract(s)Owner(s)of asset(s)Type(s)of Asset(s)Balanceamount of valueName and address(bank, insurance company, etc.)Account/policynumber, : 42 CFR Part : : No Healthcare Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.

9 *Optional if the community spouse is not requesting (Rev. 5-16) Previous edition obsolete. 2 ASSETS2. Does anyone in your household have any vehicles?c Ye s4 Check all types of assets your household has and complete the tablec Noc Carc Truckc Boatc Camper/trailerc Motorcyclec RVc Other VehicleOwner(s)(As shown on vehicle titleor registration)YearMake/ModelAmount Owed3. Has anyone in your household: sold or given away property, land, vehicles, stocks, bonds, savings, cash, checking, income, etc., closed any accounts or removed or added a name on any asset within the last 60 months?

10 C Ye s4 Who:c No filed a pending lawsuit which may bring money, property, Ye s4 Who:c No received a one-time cash payment (such as worker s compensation, lottery winnings, insurance settlement, lawsuit award, etc.) within the last 60 months?c Ye s4 Who:c No or has anyone acting for any household member, ever put any money, lawsuit settlement, income or assets in a trust, annuity or similar legal device?c Ye s4 Who:c NoAFFIDAVITI swear or affirm that all the information that I have written on this form or told to a specialist is true.


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