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Medicaid Confidential Benefits Evaluation Intake Form
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Primary Information
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Primary Contact Name
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Relationship to claimant
Select Option
Yes
No
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Are you POA?
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Primary Contact Address
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Primary Contact Phone
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Primary Contact Email Address
Tell us about Recipient (Potential Claimant)
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Name
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DOB
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Phone
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Email
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Address
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City
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State
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Zip Code
Select Option
Married
Divorce
Widowed
Single
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Are you currently
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Spouse's Name
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DOB
Health Information
In your opinion, would a doctor certify that you need assistance with daily living?
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Select Option
Yes
No
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What types of activities do you need assistance with?
Bathing
Dressing
Eating
Getting in/out of Bed
Toileting
Walking
Meals
Medications
Transportation
Security
Other
Facility/ProviderInformation
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Is anyone currently receiving medical/facility care?
Select Option
Claimant
Spouse
Both
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Are you currently in a facility?
Select Option
Yes
No
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If yes, which type of facility are you in?
Select Option
Assisted Living
Nursing Home
Independent Living
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What is the name of your facility?
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What is your monthly cost for this facility?
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Do you live at home?
Select Option
Yes
No
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Are you receiving at home care?
Select Option
Yes
No
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Who provides your at-home care?
Medical Expense Information
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Do you have long-term care insurance?
Select Option
Yes
No
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If yes, does it help pay for your current care?
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Monthly cost of your LTC?
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What amount does is cover?
Does your Medicare Premium come out of your social security check?
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Select Option
Yes
No
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If yes, please provide the monthly amount that is deducted from your check:
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Do you have supplemental Insurance?
Select Option
Yes
No
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Monthly cost of that supplemental Insurance?
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What is the name of the supplemental Insurance provider?
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Does your spouse have long-term care insurance?
Select Option
Yes
No
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If yes, does it help pay for his/her current care?
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Monthly cost ofspouse LTC?
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What daily amount does it cover?
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Does your spouse have supplemental Insurance?
Select Option
Yes
No
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Monthly cost of that insurance?
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What is the name of the supplemental Insurance provider?
FinancialInformation
Income:
Please list the
GROSS MONTHLY INCOME
for both the claimant and spouse (if applicable) and the source from which it’s received. (If not applicable put 0)
Social Security income
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Claimant
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Spouse
Pension
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Claimant
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Spouse
*
From
Interest/Dividend
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Claimant
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Spouse
Military Retirement
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Claimant
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Spouse
SSI/Public Assistance
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Claimant
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Spouse
Other
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Claimant
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Spouse
*
From
IRA Distributions
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Claimant
*
Spouse
Assets:
Please list all assets that make up your net worth in the appropriate space below:
Stocks,Bonds,Mutual Funds
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Claimant
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Spouse
Cash/Non-Interest Accounts
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Claimant
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Spouse
Interest Bearing Accounts
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Claimant
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Spouse
IRA/Retirement Accounts
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Claimant
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Spouse
Annuities
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Claimant
*
Spouse
Vehicles
*
Claimant
*
Spouse
*
Do you have a trust?
Select Option
Yes
No
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Is it Revocable, Irrevocable or unknown?
Select Option
Revocable
Irrevocable
unknown
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What date was Trust Established?
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Do you have a life insurance policy?
Select Option
Yes
No
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What is the cash value of the policy?
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Do you and/or your spouse currently own your primary residence?
Select Option
Yes
No
N/A
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What is the value of this property?
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Current Mortgage Balance?
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Do you currently have a reverse mortgage on this property?
Select Option
Yes
No
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If so, what amount?
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Do you currently own any other property or real estate?
Select Option
Yes
No
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If yes, please describe the property type and value
Do you plan on selling either the primary residence or other real estate in the near future?
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Select Option
Yes
No
I certify that the information provided istrue and correct to the best of my knowledge.
Burgos & Brein Wealth Management is a private company and is not affiliated with Medicaid, Department of Human Services, or any Federal, State or Local Government agency. Burgos & Brein Wealth Management’s evaluation of eligibility does not guarantee that a client will be found to be eligible by any Government Agency, including Medicaid or the Department of Human Services.
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