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Maryland Dhr PDF Template

The Maryland DHR form is a comprehensive application intended for individuals seeking Long-Term Care/Waiver Medical Assistance through the Maryland Department of Human Resources and the Maryland Department of Health and Mental Hygiene. It meticulously outlines the required documentation and steps applicants must follow, ensuring a thorough screening process for eligibility. Filling out this form promptly and accurately is crucial for those in need of Long-Term Care or Waiver services, as it can significantly affect the speed and outcome of the assistance application process. For a detailed guide to complete your application, click the button below.

Open Your Maryland Dhr

Outline

The Maryland Department of Human Resources along with the Department of Health and Mental Hygiene provides a critical pathway for individuals seeking long-term care through the Long-Term Care/Waiver Medical Assistance Application, encapsulating a comprehensive approach to facilitate access to necessary medical assistance. Recognized for its detailed structure, the application serves as a gatekeeper, ensuring that all requisite documentation and proofs are duly submitted for a seamless eligibility evaluation process. It emphasizes the importance of expedient application submission, hinting at a more inclusive understanding of applicants' predicaments by allowing the submission of available documents first, with a lenient window for the rest. Moreover, it delves into asset transfer details over the past five years, a crucial aspect for both applicants and their spouses, hinting at the meticulous scrutiny involved in safeguarding the integrity of the assistance program. Additionally, it provides an avenue for exploring the possibility of spouses retaining a portion of the applicant's income, thereby addressing the broader financial ramifications of long-term care on families. With a plethora of required documents ranging from federal tax returns, bank statements, to specifics about monthly income sources and even legal documentation like power of attorney, the application underscores the thoroughness in evaluating the financial landscape of applicants, ensuring a fair and equitable assessment process.

Maryland Dhr Sample

MARYLAND DEPARTMENT of HUMAN RESOURCES

MARYLAND DEPARTMENT of HEALTH and MENTAL HYGIENE

LONG-TERM CARE/WAIVER MEDICAL ASSISTANCE APPLICATION

Check List of Items Needed for Your Long-Term Care / Waiver Application

(Please keep this page for your records)

SEND PROOF If you do not already receive Long-Term Care Medical Assistance, we need the items listed below to process your application. Please send as many items as you can with this application. Please send copies, do not send originals. In some cases, we may need to request additional documents not listed below. If so, we will give you time to supply the additional documents.

DO NOT WAIT TO APPLY

If you do not have copies of all the documents listed, send in all the copies you do have when you apply. It is important to apply as soon as possible. We will give you more time to send additional documents needed.

If you or your spouse sold, traded, gifted, or disposed of any property, motor vehicles, stocks, bonds, cash or other assets in the past 5 years you will have to provide the following:

□ Type of asset	□ Reason for transfer
□ Value of asset	□ Who received the asset
□ Amount received for the asset

If you want to find out if your spouse can keep some of your monthly income, please provide:

□ Spouse’s gross monthly income	□ Property tax bill
□ Condo fees	□ Rent
□ Mortgage	□ Electric bill
□ Lot Rent

The following items are needed from you and your spouse to determine if you are eligible for Long-Term Care Medical Assistance:

□Federal Tax Returns for the current year and the preceding four years (please include all forms and schedules). A Record of Account can be obtained from the IRS free of charge by calling 1-800-908-9946 if your Federal tax returns cannot be located.

□Bank and Financial statements on all accounts owned and co-owned:

□Current Month (month of application)

□Previous Month (month prior to application)

□The last five years of the anniversary month of the application

□Current statement of retirement accounts

□Current statement of IRA or Keogh Accounts

□Current statements of:

□Stocks

□Bonds

□Money Market Funds

□Mutual Funds, Treasury, or Other Notes

□Certificates

□Current gross monthly income from all sources including:

□VA Pensions

□Railroad Retirement

□Pensions

□Annuities

□Face and cash value of Life Insurance policies (current annual statement)

□Current statement for burial accounts

□Burial Plot Deeds

□Life Estate Deeds

□Promissory Notes

□Mortgage Notes and Mortgage Deeds

□Trusts (including appendices, schedules, annual accountings, and amendments for the past five years)

□Private Health Insurance Cards including Medicare (copy of both sides)

□Health Insurance premium amounts

□Power of Attorney or Legal Guardianship Documents (if any)

Please continue by completely answering every question on the attached application. If you need more space to complete the application, please attach additional sheets.

DHR/FIA 9709 (REVISED 7-1-11)

Blank Page

DHR/FIA 9709 (REVISED 7-1-11)

MARYLAND DEPARTMENT OF HUMAN RESOURCES MARYLAND

DEPARTMENT OF HEALTH AND MENTAL HYGIENE LONG-TERM

CARE/WAIVER MEDICAL ASSISTANCE APPLICATION

Date Signed Application

Received in Local Department

MUST BE DATE STAMPED

FOR WORKER

USE ONLY

This part is for our

staff. Please continue

to Section A.

LDSS Office	Programs Applied For or		Assistance Unit IDs
	Receiving		Client ID

Worker’s Name

Application Date

Program Medical Coverage Group		AU ID

SECTION A – BENEFIT SELECTION: Please tell us about which benefits you want and which benefits you already have.

I am applying for:

Long-Term Care Waiver

Do you need Medical Assistance for medical bills incurred in the past 3 months?

If yes, you will need to provide copies of the bills to your case manager.

YES NO

Tell us if you are currently receiving other assistance.

Icurrently receive:

Medical Assistance ID #

If you already receive Medical Assistance, please provide your ID number.

Cash Assistance

Food Stamps

Other, list:

If you receive any other benefits, please list all the benefits here.

SECTION B – APPLICANT INFORMATION: Please tell us about yourself.

Last Name

First Name

Middle Name

Suffix

Maiden Name or Other Name

(Jr., Sr., etc.)

Social Security Number:

Additional Social Security Number:

If you have a Social Security Number, enter it here.

If you have an additional Social Security Number, enter it here.

Date of Birth: (Month,Day,Year)

Gender:

Male

Female

DHR/FIA 9709 (REVISED 7-1-11)

Page 1 of 17

SECTION B – APPLICANT INFORMATION (continued)

Ethnicity

Optional

	Race	1 – American Indian/Alaskan Native
1 – Hispanic or Latino	Optional –	2 – Asian
	Please choose	3 – Black/African American
	all race codes	3 – Black/African American
2 – Not Hispanic or Latino	all race codes	4 – Native Hawaiian/Pacific Islander
2 – Not Hispanic or Latino	that apply to you.	4 – Native Hawaiian/Pacific Islander
	that apply to you.	5 – White
		5 – White

You do not have to give information about your race or ethnicity. If you do, it will help show how we obey the Federal Civil Rights Law. We will not use this information to decide if you are eligible. If you do not give us your race, it will not affect your application. The case manager will enter a race code for statistical purposes only. Title VI of the Civil Rights Act of 1964 allows us to ask for this information.

Are you a resident of Maryland?

YES

Marital Status

Single

Married

Divorced

Separated

Widowed

Are you receiving Medical Assistance (Medicaid) benefits from another state?

YES

NO	If yes, please list the state:

Are you a U.S. Citizen?

YES NO

If you answered NO, please complete SECTION C – IMMIGRATION STATUS, below.

What is your primary language?

Do you need an interpreter?

YES

If you are not registered to vote,

would you like to receive a voter registration form?

YES

Already registered to vote

SECTION C – IMMIGRATION STATUS (FOR NON-CITIZENS ONLY)

SEND PROOF Please send a photocopy of the front and back of your INS card.

What is your current INS

On what date did you receive

Are you a Sponsored

What is your Country of

Status?

your INS Status?

Immigrant?

Origin?

_/_

YES

When did you enter the U.S.?

What is your INS Number?

If you are a refugee, please list your Refugee Resettlement

Agency:

DHR/FIA 9709 (REVISED 7-1-11)

Page 2 of 17

SECTION D – CURRENT ADDRESS of HOME or INSTITUTION/LONG-TERM CARE

FACILITY: Please tell us about your Long-Term Care Facility, if you live in one.

If you live in a facility, what is the name of the facility?

On what date did you enter the facility?

_/ _/

What is your home address or the address of your facility?

Street

City	_ State		_ ZIP

Telephone #		Cellular Telephone #

Is this your mailing address? YES NO If you checked NO, please provide your mailing address information in Section V.

Do you (applicant/recipient) intend to return home?

YES

Do you (applicant/recipient) intend to return home within 6 months?

YES

SECTION E – PREVIOUS ADDRESSES: Please tell us where you have lived for the past

	five years.
Street		Did you or your spouse own
		this home?

City		State	_ ZIP

YES

Street			Did you or your spouse own
			this home?
City	State	_ ZIP	YES	NO

Street			Did you or your spouse own
			this home?
City	State	_ ZIP	YES	NO

Street			Did you or your spouse own
			this home?
City	State	_ ZIP	YES	NO

SECTION F – AUTHORIZED REPRESENTATIVE: Do you authorize someone to represent you in this application? If so, please tell us about your authorized representative.

First Name

Middle Name

Last Name

Suffix

(Jr., Sr., III, etc.)


Address		_
City	State	_ZIP

DHR/FIA 9709 (REVISED 7-1-11)			Page 3 of 17

SECTION F – AUTHORIZED REPRESENTATIVE (continued)

Home Telephone #

Cellular Telephone #		_
Work Telephone #			_

What is the authorized representative’s relationship to you?

If answer is spouse, please complete the next question:

Do you or your spouse own this home?

YES NO

If Authorized Representative is your spouse, please provide spouse’s Social Security Number:

SECTION G – SPOUSAL INFORMATION: Please tell us about your spouse. Leave this section blank if your spouse is listed as your Authorized Representative in Section F.

Last Name

First Name

Middle Name

Suffix

Maiden Name or Other Name

(Jr., Sr., etc.)

Spouse’s Social Security Number

Street

Do you or your spouse own

this home?

City

State

_ ZIP

YES NO

Telephone #

SECTION H – DISABILITY: Please tell us about your disability, if you have one.

Are you disabled?

If yes, when did the disability begin?

YES

What is your disability?

				Premium Amount
Do you receive Medicare Part A?	YES	NO	$
Do you receive Medicare Part B?	YES	NO	$
Do you receive Medicare Part B?	YES	NO	$		SEND PROOF	Please send
					verification of the premium
Do you receive Medicare Part C?	YES	NO	$		amounts you pay
Do you receive Medicare Part D?	YES	NO	$
If yes, please provide your Medicare Claim Number:

DHR/FIA 9709 (REVISED 7-1-11)

Page 4 of 17

SECTION I – VETERAN INFORMATION: If you are a veteran, a disabled widow(er), or a disabled child of a deceased veteran, fill in this section:

SEND PROOF Please send a photocopy of the front and back of your military service card.

Veteran’s Name

Relationship to Veteran

Veteran’s Status

Military Service Number

SECTION J – MEDICAL INSURANCE: If the applicant/recipient is insured, fill in this section: If you have more than one policy, place additional information in Section V.

SEND PROOF Please send a photocopy of the front and back of your insurance card(s) and verification of the premium amounts you pay.

Policy Number

Group Number

Policy Holder Name

Relationship to Policy Holder

Policy Effective Dates

From:

To:

Policy Holder Address

Street

City

State

ZIP

Telephone

Insurance Company

Insurance Company Name

Street

City

State

ZIP

Telephone

Union

Union Local

Union Name

Number

Street

City

State

ZIP

Telephone

DHR/FIA 9709 (REVISED 7-1-11)

Page 5 of 17

SECTION K – INCOME FROM WORKING: Please tell us about any income you or your spouse are currently receiving from working, including any sick leave payments.

SEND PROOF Please send copies of any proof of pay, such as a paystub. If you need additional space to complete this section, please use Section V or attach additional sheets.

Employer Name

Type of Job

Employer Address

City

State_

ZIP

Telephone #

Date Job

Gross Wages per Pay Period, including tips and

Began_

Ended_

commissions.

per

Hours per Pay Period

How often do you get

If the job has ended, what is your last expected pay date?

paid?

Weekly

Biweekly

Monthly

SECTION L – YOUR BENEFITS AND OTHER INCOME: Please tell us about any income or benefits that you are receiving, have applied for, or have been denied.

SEND PROOF Please send current copies of statements that verify the gross amount of income you receive.

TYPE OF BENEFIT	RECEIVING INCOME			AMOUNT	APPLICATION		APPLICATION DATE OR
OR INCOME	OR BENEFITS?			AMOUNT		STATUS	DENIAL DATE
OR INCOME	OR BENEFITS?					STATUS	DENIAL DATE
Social Security
Please write your claim number:	YES	NO	$			Applied for
	YES	NO	$			Denied
						Denied

Black Lung Benefits	YES	NO	$			Applied for
Black Lung Benefits	YES	NO	$			Denied
						Denied
SSI (Supplemental Security
Income)						Applied for
Please write your claim number:	YES	NO	$			Applied for
Please write your claim number:	YES	NO	$			Denied
						Denied

Veteran’s Pension/Benefits	YES	NO	$			Applied for
Veteran’s Pension/Benefits	YES	NO	$			Denied
						Denied
Pension or Retirement	YES	NO	$			Applied for
Pension or Retirement	YES	NO	$			Denied
						Denied
Civil Service Annuity	YES	NO	$			Applied for
Civil Service Annuity	YES	NO	$			Denied
						Denied
Railroad Retirement Benefits
Please write your claim number:	YES	NO	$			Applied for
	YES	NO	$			Denied
						Denied

Alimony	YES	NO	$			Applied for
Alimony	YES	NO	$			Denied
						Denied
DHR/FIA 9709 (REVISED 7-1-11)							Page 6 of 17

SECTION L – YOUR BENEFITS AND OTHER INCOME (continued)


TYPE OF BENEFIT	RECEIVING INCOME			AMOUNT	APPLICATION	APPLICATION DATE OR
OR INCOME	OR BENEFITS?			AMOUNT	STATUS	DENIAL DATE
OR INCOME	OR BENEFITS?				STATUS	DENIAL DATE
Worker’s Compensation	YES	NO	$		Applied for
Worker’s Compensation	YES	NO	$		Denied
					Denied
Disability/Sick Benefits	YES	NO	$		Applied for
Disability/Sick Benefits	YES	NO	$		Denied
					Denied
Union Benefits	YES	NO	$		Applied for
Union Benefits	YES	NO	$		Denied
					Denied
Unemployment Benefits	YES	NO	$		Applied for
Unemployment Benefits	YES	NO	$		Denied
					Denied
Lump Sum Cash Amounts	YES	NO	$		Applied for
Lump Sum Cash Amounts	YES	NO	$		Denied
					Denied
Interest/Dividends from Stocks,					Applied for
Bonds, Savings, or other	YES	NO	$		Applied for
Bonds, Savings, or other	YES	NO	$		Denied
investments					Denied
investments
Business Income	YES	NO	$		Applied for
Business Income	YES	NO	$		Denied
					Denied
Other (e.g., Rental Income, or					Applied for
Compensation from a Legal	YES	NO	$		Applied for
Compensation from a Legal	YES	NO	$		Denied
Settlement)					Denied
Settlement)
Other					Applied for
Please describe:	YES	NO	$		Applied for
Please describe:	YES	NO	$		Denied
					Denied

SECTION M – ASSETS: Please tell us about your assets as of the first day of this month. Check YES or NO for each ASSET TYPE. If you check YES, fill in the other boxes. List all assets owned by you or your spouse individually, jointly, or with other persons. If you have more than one asset of the same type, use the “Other” boxes at the bottom of the list.

SEND PROOF Please send copies of current statements that verify the value of the assets.

ASSET TYPE	CHECK ONE	OWNER	AMOUNT	ACCOUNT NUMBER	INSTITUTION NAME

Cash on Hand	YES		$
Cash on Hand	NO		$
	NO

Checking Account	YES		$
Checking Account	NO		$
	NO

Savings Account	YES		$
Savings Account	NO		$
	NO

Credit Union Account	YES		$
Credit Union Account	NO		$
	NO

Trust Fund	YES		$
Trust Fund	NO		$
	NO

IRA or Keogh	YES		$
Account	NO		$
Account	NO

Other Retirement	YES		$
Accounts	NO		$
Accounts	NO

Stocks and Bonds	YES		$
Stocks and Bonds	NO		$
	NO

DHR/FIA 9709 (REVISED 7-1-11)					Page 7 of 17

SECTION M – ASSETS (continued)

	ASSET TYPE	CHECK ONE	OWNER	AMOUNT	ACCOUNT NUMBER	INSTITUTION NAME

Treasury or Other		YES		$
Notes		NO		$
Notes		NO

Annuity		YES		$
Annuity		NO		$
		NO

Ownership in a		YES		$
Company		NO		$
Company		NO

Patient Fund Account		YES		$
Patient Fund Account		NO		$
		NO

Other		YES		$
		NO		$
		NO

Other		YES		$
		NO		$
		NO

Other		YES		$
		NO		$
		NO

Other		YES		$
		NO		$
		NO

SECTION N – OTHER ASSETS: Please tell us about any other assets you own and assets jointly owned with other individuals. This could include livestock, recreational vehicles, or any other property of value such as collections of antiques, coins, jewelry, or stamps.

SEND PROOF Please send copies of current statements or documents that establish the fair market value of the asset(s) as well as the amount owed.

ASSET TYPE

CURRENT FAIR MARKET VALUE

CURRENT AMOUNT OWED

OWNER(S)

SECTION O – POTENTIAL ASSET OR INCOME: Please tell us about any accident settlement, trust fund, inheritance, or any other money, property, real property, or assistance you expect to receive.

SEND PROOF Please send copies of current statements or documents that describe the nature, amount, and payment schedule of the asset.

Asset Type

Lawyer Name

DHR/FIA 9709 (REVISED 7-1-11)

Page 8 of 17

⇓ Maryland Dhr PDF

File Breakdown

Name	Fact
Form Purpose	The form is designed for individuals applying for Long-Term Care/Waiver Medical Assistance in Maryland.
Required Documents	Applicants must provide various documents, including financial statements, tax returns, and proof of income.
Governing Departments	Handled by the Maryland Department of Human Resources and Maryland Department of Health and Mental Hygiene.
Application Urgency	Applicants are encouraged to apply as soon as possible, even if they do not have all the necessary documents at hand.
Asset Disclosure	Disclosure of asset transfers, including sales, trades, gifts, or disposal of property within the last 5 years, is required.
Spousal Information	Information on the spouse’s income and expenses might be needed to determine eligibility.
Immigration Status	Non-citizens must provide immigration status and a photocopy of their INS card.
Residency Requirement	Applicants must be residents of Maryland to apply for this assistance.
Authorized Representatives	Applicants can authorize someone to represent them in the application process.

Steps to Filling Out Maryland Dhr

Filling out the Maryland Department of Human Resources (DHR) form for Long-Term Care/Waiver Medical Assistance is a significant step in securing the support needed for long-term care or waiver services. It’s a comprehensive process that aims to establish eligibility for assistance by requiring detailed information about the applicant's finances, assets, and personal circumstances. The key to a smooth application process is preparation and attention to detail. Below are step-by-step instructions designed to guide you through each part of the form, ensuring you complete it accurately and efficiently.

Review the Checklist: Begin by reviewing the checklist of items needed for your application found on the first page. Gather as much of the listed documentation as possible before starting your application.
Complete Section A - BENEFIT SELECTION: Indicate whether you are applying for Long-Term Care Waiver, and if you need Medical Assistance for medical bills incurred in the past 3 months. If so, note that you'll need to provide copies of those bills to your case manager.
Fill in Applicant Information in Section B: Here, you'll enter your personal information, including name, Social Security Number(s), date of birth, gender, marital status, and citizenship status. Also, indicate your primary language and if you require an interpreter.
Section C - IMMIGRATION STATUS (For Non-Citizens Only): If you are not a U.S. Citizen, fill out this section with your immigration status details, including a photocopy of the front and back of your INS card.
Detail your Current Address in Section D: Provide information on your current living situation, including the address of your home or long-term care facility. Include telephone numbers and specify if this address is your mailing address.
Record Previous Addresses in Section E: List where you have lived for the past five years, specifying whether you or your spouse owned the home.
Authorize a Representative in Section F: If you wish to have someone represent you in this application process, provide their contact information here.
Sign and Date the Form at the end after ensuring all information provided is accurate and complete.
Attach all required documentation you've gathered based on the checklist. Remember, sending copies of the documents is advisable; keep the originals for your records.
Submit the Form: Review the submission instructions on the form or accompanying materials. It may require mailing to a specific address or delivering it in person to a local DHR office.

After submitting your application, the Maryland Department of Human Resources will review your information to determine eligibility for Long-Term Care/Waiver Medical Assistance. You may be contacted for additional information or to clarify the details you've provided. Ensuring the completeness and accuracy of your application can help avoid delays. Patience is essential during this period, as processing times can vary based on factors such as application volume and complexity.

More About Maryland Dhr

What is the Maryland DHR form used for?

The Maryland Department of Human Resources (DHR) form, specifically the Long-Term Care/Waiver Medical Assistance Application, is designed for individuals seeking financial assistance for long-term healthcare or waiver services. This could include assistance for nursing home care or home and community-based services for those who qualify.

Who needs to fill out the Maryland DHR form?

Any Maryland resident who is applying for long-term care medical assistance through the state's Medicaid program must complete this form. It's important for individuals entering a long-term care facility or those requiring in-home care services to fill out this application to potentially receive benefits that cover their care costs.

What documents do I need to submit with my application?

When applying, it's necessary to include various documents to verify your financial status and eligibility. These may include, but are not limited to:

Federal Tax Returns for the current and previous four years
Bank and financial statements
Statements of retirement, IRA, or Keogh accounts
Evidence of monthly income from all sources
Life insurance policies
Burial accounts and deed information
Copies of health insurance cards
Legal documents like Power of Attorney or Legal Guardianship papers, if applicable

What if I don't have all the documents right now?

It's crucial to begin your application as soon as possible, even if some documents are missing. Submit what you have, and the DHR will give you more time to provide the remaining documents needed to process your application.

How do I know if I am eligible for Long-Term Care Medical Assistance?

Eligibility is determined based on your financial situation, health needs, and residency status. Your assets, income, and the level of care you require will be assessed against the program's thresholds to decide if you qualify.

What if I have transferred or sold assets in the past 5 years?

You must disclose any transfers of assets, including sales, gifts, or disposals. Details about the type of asset, the value, whom it was transferred to, and the amount received, if any, should be provided. This information is crucial for determining eligibility.

Can my spouse keep some of my income?

Possibly, depending on your financial situation. You will need to provide information about your spouse's gross monthly income and your monthly expenses such as property taxes, mortgage, or rent, and utilities to determine if a portion of your income can be allocated to your spouse for their living expenses.

How long does it take to process my application?

The processing time can vary depending on the completeness of your application, how quickly you provide any requested additional documents, and the caseload of the DHR office handling your application. Generally, applicants can expect a decision within 45 to 90 days.

What happens after I submit my application?

Once submitted, your application will be reviewed by a case manager who may contact you for additional information or clarification. You'll receive a notice in the mail regarding the decision on your application. If approved, you'll be informed about the benefits you're eligible to receive.

Can I appeal the decision if my application is denied?

Yes, if your application is denied or if you disagree with the eligibility decision, you have the right to request a hearing. Instructions on how to appeal will be included in your notice of denial.

Common mistakes

Filling out the Maryland Department of Human Resources Long-Term Care/Waiver Medical Assistance Application requires attention to detail and accuracy. Unfortunately, several common mistakes can hinder the application process, potentially delaying or affecting approval. Below are eight mistakes often made during this process:

Not providing complete documentation: Applicants sometimes fail to send all the necessary documents, such as financial statements for the previous five years or proof of income. This oversight can significantly delay the process.
Sending original documents instead of copies: The checklist advises sending copies of required documents, not the originals. Sending originals poses a risk of important documents getting lost.
Delaying the application: Some individuals wait until they have gathered all potential documentation before applying. It's crucial to apply as soon as possible and submit additional documents later if needed.
Incorrectly reporting asset transfers: The failure to correctly report the sale, trade, gift, or disposal of assets within the past five years can lead to an eligibility issue.
Omitting information about other benefits: Not disclosing current benefits such as Medical Assistance, food stamps, or cash assistance can impact the processing of your application.
Inaccurate personal information: Mistakes in basic information like Social Security numbers, birth dates, or marital status can lead to delays in processing.
Failure to provide detailed health insurance information: Not including details about private health insurance, Medicare cards, and premium amounts can affect eligibility and the accuracy of the application.
Not using additional sheets when necessary: Some applicants try to fit all their information into the provided space, which can lead to incomplete or illegible entries. Attaching additional sheets ensures clarity and completeness.

By avoiding these common mistakes, applicants can speed up the processing of their Long-Term Care/Waiver Medical Assistance Application and improve their chances of approval. It's essential to read the application instructions carefully and provide as much detailed information as possible.

Documents used along the form

When preparing for long-term care or waiver medical assistance in Maryland, it's crucial to not only fill out the Maryland Department of Human Resources (DHR) form but also gather other essential documents. These additional documents ensure a thorough and comprehensive application process, covering all aspects of your or your loved's one financial, medical, and personal situation. Here's a brief overview of other commonly required documents:

Proof of Identity and Age: This includes a government-issued photo ID such as a driver's license or passport, and a birth certificate to verify the applicant's identity and date of birth.
Social Security Card: A copy of the applicant's Social Security card is required to verify their Social Security number, a key piece of information for identification and eligibility purposes.
Proof of Citizenship or Immigration Status: Documents such as a naturalization certificate, U.S. passport, or Permanent Resident Card (Green Card) may be needed to establish U.S. citizenship or lawful presence in the country.
Proof of Residence: Utility bills, lease agreements, or mortgage statements can be used to verify the applicant's Maryland residency.
Income Verification Documents: This may include pay stubs, Social Security benefits statements, pension statements, and other documents that provide evidence of income from all sources.
Asset Documentation: Bank statements, investment records, property deeds, and vehicle registration documents are necessary to assess the applicant's financial situation comprehensively.
Medical Records and Prescription Information: Documentation related to the applicant's health condition, treatments received, and medications prescribed are important for determining the level of care needed.
Insurance Policies: Copies of health insurance cards, policy documents for life insurance, long-term care insurance, and other relevant insurance policies should be included to evaluate coverage and benefits.

Collecting these documents along with the Maryland DHR form lays a solid foundation for your application process. It provides a clear picture of your or your loved one's eligibility for medical assistance and ensures that no detail is overlooked. Taking the time to gather and organize these documents can streamline the application process and help secure the necessary support for long-term care or health services.

Similar forms

The Maryland Department of Human Resources (DHR) form for long-term care/waiver medical assistance application shares similarities with other forms and documents used in the process of applying for various types of government assistance programs. One such document is the Application for Supplemental Security Income (SSI) used by the Social Security Administration (SSA).

Like the Maryland DHR form, the Application for SSI requires applicants to provide detailed information regarding their financial status, including assets, income, and living arrangements. Both forms are designed to assess eligibility for assistance based on financial need and certain other criteria. However, while the SSI application is focused primarily on providing income support to individuals who are aged, blind, or disabled, the Maryland DHR form is specific to those seeking medical assistance for long-term care or waiver services. Despite these differences, the purpose of gathering exhaustive financial information remains a common thread, underlining the importance of transparency in the evaluation process for assistance eligibility.

Another document similar to the Maryland DHR form is the Medicaid application commonly used in many states. This form also collects comprehensive information about an individual's financial situation, health coverage needs, and personal identification details. Both documents are geared towards establishing the applicant’s eligibility for health benefits, with a particular focus on those with limited income and resources. The Medicaid application, similar to the Maryland DHR form, may require information on assets transferred within the last five years, current income from all sources, and insurance policies, among other data. These parallels highlight the rigorous requirements set forth by government assistance programs to ensure that aid is provided to those who meet the eligibility criteria.

Dos and Don'ts

Filling out the Maryland Department of Human Resources (DHR) long-term care/waiver medical assistance application is a critical step in securing the necessary assistance for long-term care. To guide you seamlessly through this process, here are pivotal dos and don'ts:

Do gather all the required documents mentioned in the checklist before starting your application. This includes tax returns, bank statements, insurance policies, and proof of income, among others.
Don’t procrastinate on applying. If you are missing some documents, submit what you have and provide the rest as soon as you can. Delays in submission can affect your eligibility or the timely provision of assistance.
Do make copies of all documents you’re sending with your application. Keeping originals is crucial as they may be required again in the future or for other purposes.
Don’t fill out the form in a hurry. Take your time to accurately answer each question. Incorrect or missing information can lead to delays in processing your application.
Do ask for help if you need it. If any part of the application is unclear, contact the Maryland Department of Human Services for guidance instead of guessing the answers.
Don’t forget to report any transfers of assets in the past 5 years. This includes anything you might have sold, gifted, or disposed of, as it could impact your eligibility.
Do provide detailed information about your and your spouse’s income and assets, if applicable. Essential expenses like rent, mortgages, and utility bills should also be accurately reported.
Don’t ignore the need for proof of residency and citizenship (or legal immigration status) and the potential need for an interpreter if English is not your primary language.
Do ensure that your application is complete, signed, and dated. Review your application carefully to avoid missing out on vital sections or information.

Adhering to these guidelines will facilitate a smoother application process, reducing stress and uncertainty while ensuring that you’re taking the right steps toward securing long-term care assistance.

Misconceptions

Understanding the Maryland DHR form, particularly for those applying for Long-Term Care/Waiver Medical Assistance, is crucial. However, several misconceptions can complicate the application process. Let's debunk some common myths:

Everything must be completed in one sitting. This misconception pressures applicants, believing that if they don't have all necessary documents at hand, they can't start the application process. In reality, it's encouraged to begin your application as soon as possible and submit additional documents as they become available.
Original documents are required. Applicants often worry about sending original documents through the mail. Fortunately, the form explicitly states that copies of the required documents are perfectly acceptable. Always keep your originals safe with you.
Asset transfers (e.g., gifts, sales) disqualify you automatically. While significant financial transactions, especially those within the last five years, must be disclosed, they don't outright disqualify an applicant. Each situation is reviewed individually, considering the context of the transfer.
Only income sources directly in your name count. In reality, the income of both the applicant and their spouse is considered in determining eligibility for assistance, regardless of whose name is on the source of income.
All medical expenses need to be paid out-of-pocket until approved. The form asks if you need assistance with medical bills from the past three months, implying that some retroactive financial support is available. This can alleviate the immediate financial burden while your application is processed.
The application only covers individual long-term care. The wording might make it seem as though the assistance is strictly for individual care in a long-term facility. However, "Waiver" applicants could receive help to cover home-based or community services, broadening the scope of support.
Legal documentation is unnecessary. The form requests copies of legal documents like Power of Attorney or Legal Guardianship documents if they exist. These documents are crucial in establishing who has the legal right to make decisions on behalf of the applicant, making them far from unnecessary.
Your voter registration status is irrelevant. While it may seem off-topic, the form does inquire about voter registration, demonstrating the state's holistic approach to civic engagement and support for its residents. It doesn't affect your eligibility but exemplifies a commitment to keeping all citizens involved and informed.

By understanding these aspects of the Maryland DHR form, applicants can navigate the process more effectively and with less stress. It's all about knowing the facts and preparing accordingly to ensure a smooth journey through the application process for Long-Term Care/Waiver Medical Assistance.

Key takeaways

Filling out the Maryland Department of Human Resources Medical Assistance Application for long-term care or waiver services involves several critical steps and requirements. It's essential to provide accurate and complete information to ensure your application is processed efficiently. The following are key takeaways to guide applicants through this process:

Ensure all required documents are gathered and submitted with your application. These documents include, but are not limited to, proof of income, bank and financial statements, insurance policies, and tax returns for the current and previous four years.
Do not send original documents. Make copies of all required documents to send with your application, keeping the originals for your records.
Apply as soon as possible. If you do not have all the necessary documents at the moment, submit what you have. You will be given time to provide any additional requested information.
Details regarding the disposal of assets in the past 5 years, such as selling, trading, gifting, etc., must be thoroughly documented and included.
Include information about your spouse's income and expenses if you wish to find out if they can retain a portion of your income to meet their needs.
Completing the application accurately is crucial. Attach additional sheets if you need more space to provide comprehensive answers to all questions.
Your current immigration status and whether you are a sponsored immigrant will require proof, which must be included with your application.
Designating an authorized representative is optional but could be beneficial. If you choose to do so, provide their complete contact information within the designated section of the application form.
Update your address promptly if it changes during the application process to ensure you receive all communications regarding your application.

By following these guidelines, applicants can navigate the process of applying for Medicaid assistance for long-term care or waiver services in Maryland more smoothly. It is important to fill out the application form carefully and provide all the required documents to avoid delays in the approval process.

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