Fillable MAABD ADDENDUM MEDICAID STATE OF NEVADA DEPARTMENT OF (State of Nevada, Department of Information Technology)

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MAABD ADDENDUM MEDICAID STATE OF NEVADA DEPARTMENT OF (State of Nevada, Department of Information Technology)

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BROWSE STATE OF NEVADA, DEPARTMENT OF INFORMATION TECHNOLOGY (NV) FORMS

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STEVE SISOOLAK
Governor
STATE OF NEVADA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF WELFARE AND SUPPORTIVE SERVICES
RICHARD WHITLEY, MS
Director
STEVE H. FISHER
Administrator
2059 - EM (242.0.0)
Page 1 of 3
MEDICAID
Date:
Case Name:
Case ID:
MAABD ADDENDUM
Please complete the following questions so your application for medical assistance can be evaluated properly.
Have you or your spouse been in a hospital, nursing home or other medical institution
during the past 3 months? Self Spouse
Are you or your spouse currently in a hospital, nursing home or other medical facility? Yes No
If yes, who: Date Entered: Date Left:
Facility Name/Address:
Have you or your spouse been injured in an accident? Yes No Who: When:
If you or your spouse resides in a medical facility, regardless of medical condition, do you intend to return
home? Yes No
Please check the box for all resources you or a member of your household have:
None Individual Indian Money Accounts (IIM) Other Account Types
Burial Funds/Plans Individual Retirement Accounts (IRA) Other Houses, Land or Buildings
Business Checking Accounts Keogh Accounts (401K) Promissory Notes or Contracts
Business Equipment/Inventory Land/Mineral Rights Safe Deposit Box
Cash on hand
$
Life Estates/Life Leases Savings Accounts
Certificates of Deposit (CD) Life Insurance Policies Savings Bonds
Checking Accounts Livestock/Horses Stocks/Bonds
Christmas Club Mining Claims The Home You Live In
Credit Union Accounts Available Trust Funds Unavailable Trust Funds
Other
If you have checked any boxes above, please provide details below.
Owner(s) Resource Type Account/Policy # Value Amount Owed
Are any of the resources listed above designated for burial? Yes No Which one?
2059 - EM (242.0.0)
Page 2 of 3
List all cars, trucks, recreational vehicles, trailers, etc. you own or are purchasing. Include vehicles that are not
currently running.
Owner(s)
Year, Make
and Model Value Registered? Owner(s)
Year, Make
and Model Value Registered?
Has anyone transferred, sold, traded or given away money, vehicles, property or other resources, closed any
bank accounts or purchased annuities in the last 60 months?
Yes No
If yes, list date: What was given: Value: Total Sale Price:
Have you or your spouse executed a trust, annuity, court order and/or purchased a promissory note, loan or life
estate?
Yes No If yes, attach a copy(ies) of the document(s) with this application.
Be aware that by virtue of the provisions of medical assistance for institutional care, amenities purchased on or
after February 8, 2006 must name the State of Nevada as remainder beneficiary.
INCOME INFORMATION
Do you or your spouse receive income from any source other than Social Security?
Yes No
Person Frequency Amount
2059 - EM (242.0.0)
Page 3 of 3
SPOUSE INFORMATION
Please complete the following about your current and previous spouse, even if you are separated, but not divorced.
If your spouse is deceased, all possible information must still be completed.
Spouse Name:
Address:
Social Security #: Date of Birth:
Are you divorced? Yes No
Date of Divorce:
Are you separated? Yes No
Date separated:
Are you widowed? Yes No
Date Widowed:
Employer Name/Address: Medical Insurance Information:
Are you covered?
Yes No
Railroad, federal or local government employee? Yes No
Railroad or government Claim #:
Years employed:
Veteran? Yes No Claim #:
Spouse Name:
Address:
Social Security #: Date of Birth:
Are you divorced? Yes No
Date of Divorce:
Are you separated? Yes No
Date separated:
Are you widowed? Yes No
Date Widowed:
Employer Name/Address: Medical Insurance Information:
Are you covered?
Yes No
Railroad, federal or local government employee? Yes No
Railroad or government Claim #:
Years employed:
Veteran? Yes No Claim #:
In order to assist us in processing your application timely, please provide verification of any income and resources
you have listed on this form. Provide copies of the most current bank statement for all accounts, value of life
insurance policies, and vehicle registration.
/ /
Client Signature Print Name Date Telephone Number
Spouse Signature Print Name Date Telephone Number
For Office Use Only
Telephone call to applicant (Date): Copy of form mailed to applicant (Date):
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MAABD ADDENDUM MEDICAID STATE OF NEVADA DEPARTMENT OF (State of Nevada, Department of Information Technology)

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Completed 13 May 2021

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