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MARYLAND DEPARTMENT of HUMAN RESOURCES MARYLAND DEPARTMENT of (State of Maryland)

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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
□ Condo fees
□ Mortgage
□ Lot Rent
□ Property tax bill
□ Rent
□ Electric bill
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)
Date Signed Application
Received in Local Department
MUST BE DATE STAMPED
MARYLAND DEPARTMENT of HUMAN RESOURCES
MARYLAND DEPARTMENT of HEALTH and MENTAL HYGIENE
LONG-TERM CARE/WAIVER MEDICAL ASSISTANCE APPLICATION
FOR WORKER
USE ONLY
LDSS Office
Programs Applied For or
Receiving
Client ID
Worker’s Name
This part is for our
staff. Please continue
to Section A.
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.
I currently
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:
If you have a Social Security Number, enter it here.
___________________________________________
Additi
onal Social Security Number:
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
1 – Hispanic or Latino
2 – Not Hispanic or Latino
Race
Optional –
Please choose
all race codes
that apply to you.
1 – American Indian/Alaskan Native
2 – Asian
3 – Black/African American
4 – Native Hawaiian/Pacific Islander
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 NO Marital Status Single
Married
Divorced
Separated
Widowed
Are
you receiving Medical Assistance
YES NO
(Medicaid) benefits from another state?
If yes, please list the state:
_______________________________________________
Are
you a U.S. Citizen?
YES NO
What is your primary language?
If y
ou answered NO, please complete SECTION C –
_______________________________________________
IMM
IGRATION STATUS, below
.
Do you need an interpreter? YES NO
If y
ou are not registered to vote,
would you like to receive a voter registration form?
YES NO 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
Status?
_______________________
On what date did you receive
your INS Status?
______/_______/_______
Are you a Sponsored
Immigrant?
YES NO
What is your Country of
Origin?
_____________________
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 NO
Do you (applicant/recipient) intend
to return home within 6 months?
YES NO
SECTION E – PREVIOUS ADDRESSES: Please tell us where you have lived for the past
five years.
Street _____________________________________________________________________
City ___________________________ State ___________ ZIP ______________________
Did you or your spouse own
this home?
YES NO
Str
eet
_____________________________________________________________________
City ___________________________ State ___________ ZIP ______________________
Did you or your spouse own
this home?
YES NO
Street _____________________________________________________________________
City ___________________________ State ___________ ZIP ______________________
Did you or your spouse own
this home?
YES NO
Street
_____________________________________________________________________
City ___________________________ State ___________ ZIP ______________________
Did you or your spouse own
this home?
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 A
uthorized 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 _______________________________________________________________________
Str
eet
___________________________________________________________________
City ___________________________ State ___________ ZIP ____________________
Telephone # _______________________
Do you or your spouse own
this home?
YES NO
SECTION H – DISABILITY: Please tell us about your disability, if you have one.
Are you disabled? YES NO
If yes, when did the disability begin?
___________/____________/____________
What
is your disability?
_________________________________________________
_________________________________________________
Do you receive Medicare Part A? YES NO
Do you receive Medicare Part B? YES NO
Do you receive Medicare Part C? YES NO
Do you receive Medicare Part D? YES NO
Premium Amount
$ ______________________
$ ______________________
$ ______________________
$ ______________________
SEND PROOF
Please send
verification of the premium
amounts you pay
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
Vet
eran’s Status
Mil
itary 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 Name _______________________________________________________
Union Local
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
Began___________________
Date Job
Ended______________
Gross Wages per Pay Period, including tips and
commissions.
$________________ per ___________________
Hours per Pay Period
_________________________
How often do you get
paid?
Weekly
Biweekly
Monthly
If the job has ended, what is your last expected pay date?
_________________________________________________
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
OR INCOME
RECEIVING INCOME
OR BENEFITS?
AMOUNT
APPLICATION
STATUS
APPLICATION DATE OR
DENIAL DATE
Social Security
Please write your claim number:
YES NO $
Applied for
Denied
Black Lung Benefits YES NO $
Applied for
Denied
SSI (Supplemental Security
Income)
Please write your claim number:
YES NO $
Applied for
Denied
Veteran’s Pension/Benefits YES NO $
Applied for
Denied
Pension or Retirement YES NO $
Applied for
Denied
Civil Service Annuity YES NO $
Applied for
Denied
Railroad Retirement Benefits
Please write your claim number:
YES NO $
Applied for
Denied
Alimony YES NO $
Applied for
Denied
DHR/FIA 9709 (REVISED 7-1-11)
Page 6 of 17
SECTION L – YOUR BENEFITS AND OTHER INCOME (continued)
TYPE OF BENEFIT
OR INCOME
RECEIVING INCOME
OR BENEFITS?
AMOUNT
APPLICATION
STATUS
APPLICATION DATE OR
DENIAL DATE
Worker’s Compensation YES NO $
Applied for
Denied
Disability/Sick Benefits YES NO $
Applied for
Denied
Union Benefits YES NO $
Applied for
Denied
Unemployment Benefits YES NO $
Applied for
Denied
Lump Sum Cash Amounts YES NO $
Applied for
Denied
Interest/Dividends from Stocks,
Bonds, Savings, or other
investments
YES NO $
Applied for
Denied
Business Income YES NO $
Applied for
Denied
Other (e.g., Rental Income, or
Compensation from a Legal
Settlement)
YES NO $
Applied for
Denied
Other
Please describe: YES NO $
Applied for
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
NO
$
Checking Account
YES
NO
$
Savings Account
YES
NO
$
Credit Union Account
YES
NO
$
Trust Fund
YES
NO
$
IRA or Keogh
Account
YES
NO
$
Other Retirement
Accounts
YES
NO
$
Stocks and Bonds
YES
NO
$
DHR/FIA 9709 (REVISED 7-1-11)
Page 7 of 17
_______________
_______________
_______________
_______________
SECTION M – ASSETS (continued)
ASSET TYPE
Treasury or Other
Notes
Annuity
Ownership in a
Company
Patient Fund Account
Other
Other
Other
Other
CHEC
K ONE
OWNER
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
YES
NO
AMOUNT
$
$
$
$
$
$
$
$
ACCO
UNT NUMBER
INST
ITUTION NAME
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
SECTION O – POTENTIAL ASSET OR INCOME (continued)
Explanation
____________________________________________________________
Anticipated
Date of Receipt
_______________________________________________
Lawyer Telephone #
____________________________________
SECTION P – REAL PROPERTY: Please tell us about any real property that you own in or out of
the state of Maryland.
SEND PROOF Please send a copy of the deed to each property. Please also send copies of current documents that verify
the equity value of each property.
Do
you and/or your spouse own or have a legal interest in any other real property?
YES NO
If yes, please answer the following questions:
ADDRESS OF PROPERTY
TYPE OF OWNERSHIP
(CHECK ONE)
CURRENT FAIR MARKET VALUE CURRENT AMOUNT OWED
Rental Property
Vacation Property
Time Share
Vacant Land
Other Property Rights
Burial Plot
$ $
Rental Property
Vac
ation Property
Time Share
Vacant Land
Other Property Rights
Burial Plot
$ $
Rental Property
Vac
ation Property
Time Share
Vacant Land
Other Property Rights
Burial Plot
$ $
Rental Property
Vac
ation Property
Time Share
Vacant Land
Other Property Rights
Burial Plot
$ $
DHR/FIA 9709 (REVISED 7-1-11)
Page 9 of 17
SECTION Q – LIFE INSURANCE AND FUNERAL PLANS: Please tell us about any life
insurance or pre-paid burial plans or funds that you own. Please list all policies and
funds, no matter who pays for them.
SEND PROOF Please send a copy of the declaration page of each policy. Please also send copies of current statements to
verify the cash value of each policy, if applicable.
ORIGINAL FACE
VALUE OR VALUE OF
PLAN
CASH VALUE TYPE OF PLAN
POLICY NUMBER
OR ACCOUNT
NUMBER
POLICY OWNER
COMPANY,
FUNERAL
HOME, OR
BANK NAME
$ $
Life Insurance
Burial Plan
$ $
Life Insurance
Burial Plan
$ $
Life Insurance
Burial Plan
SECTION R – TRANSFER OF ASSETS: Please tell us about any assets that you sold, traded,
gifted, or disposed of in the past five years. This could include personal and real
property, motor vehicles, stocks, bonds, cash, or other assets.
SEND PROOF Please send copies of current statements or documents that verify the date the asset was transferred, the
value of the asset at the time of the transfer, and the amount you received for the transferred asset. If you
need additional space to complete this section, please use Section V or attach additional sheets.
TRANSFER DATE TYPE OF ASSET
VALUE OF THE ASSET AT
THE TIME OF THE
TRANSFER
WHO RECEIVED THE
ASSET AND THE REASON
FOR THE TRANSFER
AMOUNT RECEIVED
$
$
$
SECTION S – SPOUSAL BENEFITS AND OTHER INCOME: Please tell us about any income
or benefits that your spouse is receiving, has applied for, or has been denied.
SEND PROOF Please send current copies of statements that verify the gross amount of income your spouse receives.
TYPE OF BENEFIT
RECEIVING
BENEFITS?
AMOUNT
APPLICATION
STATUS
APPLICATION DATE OR
DENIAL DATE
Social Security
Please write your claim number:
YES NO $
Applied for
Denied
Black Lung Benefits YES NO $
Applied for
Denied
SSI (Supplemental Security Income
Please write your claim number:
YES NO $
Applied for
Denied
DHR/FIA 9709 (REVISED 7-1-11)
Page 10 of 17
SECTION S – SPOUSAL BENEFITS AND OTHER INCOME (continued)
TYPE OF BENEFIT
RECEIVING
BENEFITS?
AMOUNT
APPLICATION
STATUS
APPLICATION DATE OR
DENIAL DATE
Veteran’s Pension/Benefits YES NO $
Applied for
Denied
Pension or Retirement YES NO $
Applied for
Denied
Civil Service Annuity YES NO $
Applied for
Denied
Railroad Retirement Benefits
Please write your claim number:
YES NO $
Applied for
Denied
Alimony YES NO $
Applied for
Denied
Worker’s Compensation YES NO $
Applied for
Denied
Disability/Sick Benefits YES NO $
Applied for
Denied
Union Benefits YES NO $
Applied for
Denied
Unemployment Benefits YES NO $
Applied for
Denied
Lump Sum Cash Amounts YES NO $
Applied for
Denied
Interest/Dividends from Stocks,
Bonds, Savings, or other investments
YES NO $
Applied for
Denied
Other
Please describe:
YES NO $
Applied for
Denied
Other
Please describe:
YES NO $
Applied for
Denied
Other
Please describe:
YES NO $
Applied for
Denied
SECTION T – SPOUSAL NEEDS (SPOUSAL IMPOVERISHMENT): If you have a living
spouse, fill in this section. List all assets owned in the month the applicant was
admitted to a long-term care facility. Include all assets owned individually or jointly by
the applicant, or owned individually or jointly by your spouse.
SEND PROOF Please send copies of statements that verify the value of the assets.
ASSET TYPE
Cash on Hand
Checking Account
Savings Account
CHECK
ONE
YES
NO
YES
NO
YES
NO
OW
NER AMOUNT
$
$
$
AC
COUNT NUMBER
IN
STITUTION NAME
DHR/FIA 9709 (REVISED 7-1-11)
Page 11 of 17
SECTION T – SPOUSAL IMPOVERISHMENT (continued)
ASSET TYPE
CHECK
ONE
OWNER AMOUNT ACCOUNT NUMBER INSTITUTION NAME
Cr
edit Union Account
YES
NO
$
Tr
ust Fund
YES
NO
$
IR
A or Keogh Account
YES
NO
$
Ot
her Retirement
Accounts
YES
NO
$
St
ocks and Bonds
YES
NO
$
Cer
tificates and
Money Market Funds
YES
NO
$
Tr
easury or Other
Notes
YES
NO
$
Ann
uity
YE
S
NO
$
Ow
nership in a
Company
YES
NO
$
Ot
her
_______________
YES
NO
$
Ot
her
_______________
YES
NO
$
Ot
her
_______________
YES
NO
$
SECTION U – RESIDENTIAL, SPOUSAL, OR DEPENDENT ALLOWANCE
Have you or your spouse been in an institution/Long-Term Care Facility in the past? YES NO
If yes, please provide the following:
Date Entered Institution/
Long-Term Care Facility ____________________ Name of the Facility _______________________________________
Is
there a spouse, child under 21, or any other dependent relatives at home? YES NO
If YES, fill in the section below. If you need additional space for assets for dependent children and relatives at home, please use Section
V or attach additional sheets.
GROSS
VALUE OF
NAME RELATIONSHIP AGE
MONTHLY
INCOME
TYPE OF INCOME ASSET ASSET TYPE
SEND PROOF
SEND PROOF
$ $
DHR/FIA 9709 (REVISED 7-1-11)
Page 12 of 17
SECTION U – RESIDENTIAL, SPOUSAL, OR DEPENDENT ALLOWANCE (continued)
NAME
$ $
$ $
RELATIONSHIP AGE
GROSS
MONTHLY
INCOME
SEND PROOF
TYPE OF INCOME
VALUE OF
ASSET
SEND PROOF
ASSET TYPE
If
applicant/recipient intends to return home within six months and if there is no spouse, child under 21, or other dependent
relatives, fill in the section below:
SEND PROOF
Please provide your most recent statements to verify the expenses you listed below:
Rent/Mortgage
$
___________________________
Home Owner’s Insurance
$
___________________________
Utilities
$
____________________
Condo Fees
$
____________________
Heat (if separate from utilities)
$
_____________________________
Other Shelter Costs (Specify)
$
_____________________________
Property Taxes
$
__________________________
Other Shelter Costs (Specify)
$
__________________________
SECTION V – ADDITIONAL INFORMATION: Please use this area for any information that
would not fit in the spaces provided on this application.
DHR/FIA 9709 (REVISED 7-1-11)
Page 13 of 17
SECTION W – TAX RETURNS: Please tell us about any tax returns filed by you and/or your
spouse in the last five years.
Did you or your spouse file Federal income tax returns in the last five years? YES NO
SEND PROOF Please send copies of Federal tax returns for the current year and the preceding four years, including all
forms and schedules.
SECTION X – PRE-ELIGIBILITY MEDICAL EXPENSES (NON-COVERED SERVICES):
Please tell us about any unpaid medical bills that you incurred in the last three months.
You may be eligible for deductions from your income.
Do you have any unpaid medical bills that you incurred in the last three months? YES NO
SEND PROOF If you answered yes, provide a newly dated, itemized, unpaid medical bill(s) that you incurred up to three
months prior to this application. The bill must contain a service date, charge, and a detailed description of the service(s)
provided. Attach copies of the bill(s) to the form and submit them with your Long-Term Care Medical Assistance application.
If you do not have the bills at the time you submit the application, the bills may be submitted at a later date during this
application process.
Please check one of the YES o
r NO choices below and sign where you have indicated your choice:
YES, I HAVE unpaid medical bills from the last three months.
I am sending copies of my bills with this application.
I will send copies of my bills at a later date during this application process.
Si
gnature:
_____________________________________ (Applicant)
Date: ____________________________
Si
gnature:
_____________________________________ (Authorized Representative)
Dat
e:
____________________________
NO, I DO NOT HAVE unpaid medical bills at this time.
Si
gnature:
_____________________________________ (Applicant)
Dat
e:
____________________________
Si
gnature:
_____________________________________ (Authorized Representative)
Dat
e:
_____________________________
DHR/FIA 9709 (REVISED 7-1-11)
Page 14 of 17
MARYLAND DEPARTMENT of HUMAN RESOURCES
MARYLAND DEPARTMENT of HEALTH and MENTAL HYGIENE
LONG-TERM CARE/WAIVER MEDICAL ASSISTANCE APPLICATION
RIGHTS AND RESPONSIBILITIES
I UNDERSTAND I HAVE THE FOLLOWING RIGHTS:
The Department cannot discriminate against me. Federal and State law prohibit the Department from
discriminating against me because of race, color, national origin, sex, age, or disability. If I think the Department has
discriminated against me, I may contact the U.S. Department of Health and Human Services at: HHS, Director,
Office for Civil Rights, Room 506-F, 200 Independence Avenue, S.W., Washington, D.C. 20201 or by calling 202-
619-0403 (voice) or 202-619-3257 (TDD).
I have the right to privacy of my personal information. I am providing personal information (that includes, but is
not limited to: name, address, date of birth, Social Security number, income history, employment history, medical
history) in this application for Medical Assistance. The purpose of requesting this personal information is to
determine my eligibility for Medical Assistance. If I do not provide this information, the Department may deny my
application for benefits. I have a right to inspect, amend, or correct this personal information. The Department will
not permit inspection of my personal information, or make it available to others, except as permitted by Federal and
State law. I understand, however, that the Department may deny my application for Medical Assistance if I do not
provide this information.
If my case is approved, the Department will provide me with a written notice explaining my benefits. The
Department must give me written notice when it changes my benefits or, determines that I am ineligible for Medical
Assistance. I have 90 days from the date of the notice to request a hearing. If I am already receiving benefits and
request a hearing within 10 days from the date of the notice, I may continue to receive benefits while I wait for the
hearing. Any erroneous benefits I receive from the Department must be repaid to the Department.
I have the right to appeal certain actions taken by the Department. I can request a hearing if: my application for
Medical Assistance eligibility is denied; I assert the Department’s decision about Medical Assistance services was
erroneous; or, there was a delay in the Department’s action(s) related to my application. I may call the Department
at 1-800-332-6347 for help requesting a hearing. I am responsible for providing the reason for requesting a hearing.
At the hearing, I may speak for myself or I may be accompanied by a lawyer, friend, or relative to speak on my
behalf.
IF I ACCEPT MEDICAL ASSISTANCE, I UNDERSTAND BY SIGNING THIS APPLICATION:
Payment Authorization - I authorize payment under Medicare Part B to be made directly to health care providers
and medical suppliers.
Assignment of Health Insurance/Third Party Payments - I assign all rights, title, and interest of health insurance
payments I may have to the Department and give the Department the right to seek payment from private or public
health insurance and any liable third party for the costs the Department incurs for the benefits I receive under
Medical Assistance. The Department may seek payment without legal action, providing it does not keep more than
the amount Medical Assistance paid. I agree to promptly forward, to the Department, any health insurance
payments I receive, including payments received as a settlement from an accident.
Access to Records - I give the Department the right to inspect, review, and copy all relevant portions of my medical
records for purposes of determining my eligibility for, and for determining the appropriateness of the services
received through, the Medical Assistance program.
Quality Review Cooperation - I understand that the Department may select my case for a random check or audit
for quality control purposes. I agree to allow any representative from the Department to visit me where I reside. I will
fully assist the Department in retrieving all proof needed from any source.
Estate Recovery - I understand that the Department may recover, from the estate of a deceased Medical
Assistance recipient, Medical Assistance payments made on his or her behalf on or after the person attained age 55.
The Department may recover only if there is no surviving spouse, unmarried child younger than 21, or blind or
disabled child (married or unmarried) of any age.
Accurate and Confidential Application Information - I acknowledge that I must provide true, correct, and
complete information and provide proof of this information.
DHR/FIA 9709 (REVISED 7-1-11)
Page 15 of 17
_____________________________________________________________ ___________________________________
Social Security Number(s) - I must provide my (and my spouse’s) Social Security number as an applicant for
Medical Assistance. The Department will use the Social Security number(s) and other information I provide to verify
the information I provide for program reviews. The Department will do this to make sure I am eligible. The
Department may also verify my information by contacting my employer, bank, or other parties; and/or, the
Department may contact local, State, or Federal agencies to make sure the information I provide is correct. If I do
not have a Social Security number, I must apply for one and the Department can provide assistance in applying for a
number.
Accurate Financial Reporting - I understand that I am responsible for reporting true, correct, and complete financial
information. This includes, but is not limited to information about: all my assets; potential assets; transfer of assets
within the last 5 years of my initial application; transfer of assets within the last 12 months of the date of the annual
redetermination of my eligibility; income; insurance; real property; annuities; and all other benefits I may be receiving.
I understand that Federal law requires that, as a condition of receiving long-term care services, the Department must
be named, in my annuity, as the primary remainder beneficiary.
Report Changes - I am responsible for reporting changes in my situation. I must report changes within 10 days.
The best way for me to report changes is in writing. Examples of changes in my situation are changes in my income,
assets, address, health insurance premiums, or persons living in my home. My representative (person acting on my
behalf who may file my application) is responsible for reporting such changes. Changes must be reported to the
appropriate Local Department of Social Services or the Bureau of Long-Term Care Eligibility.
Medical Assistance Card Misuse - If I become eligible for Medical Assistance, I must use my Medical Assistance
card properly. It is against the law to allow another person to use my card.
Medical Assistance Fraud - If I do not report true, correct, and complete information, or report changes, the
Department may deny, stop, or reduce my benefits. A judge may fine me and/or imprison me if I intentionally do not
give correct information or report changes.
SIGNATURES:
I swear or affirm that I have read or had read to me this entire application. I also swear or affirm, under penalty or perjury,
that all the information I have given is true, correct, and complete to the best of my ability, knowledge and belief. I have
received a copy of my rights and responsibilities. I authorize any person, partnership, corporation, association, or
governmental agency which knows the facts relevant to determining my eligibility to release that information to the
Department. I also authorize the Department to contact any person, partnership, corporation, association, or governmental
agency that has provided information relevant to my eligibility for benefits. I certify, under penalty of perjury, by signing my
name below, that the person for whom I am applying is a U.S. citizen or lawfully admitted immigrant.
Signature of
Applicant/Recipient ______________________________________________________ Date__________________
Signature of Witness
(If you Signed an X) _______________________________________________________ Date__________________
Signature of Spouse
(If applicable) _______________________________________________________ Date__________________
Signature of Authorized
Representative (if applicable)_____________________________________________________ Date__________________
I withdraw my application for Medical Assistance
Signature of Applicant, Recipient, or Authorized Representative Date
Signature of Case Manager
Date
DHR/FIA 9709 (REVISED 7-1-11)
Page 16 of 17
_________________________________________________________ _____________________
_________________________________________________________ _____________________
________________________________ _________________________ _____________________
________________________________ _________________________ _____________________
MARYLAND DEPARTMENT of HUMAN RESOURCES
MARYLAND DEPARTMENT of HEALTH and MENTAL HYGIENE
LONG-TERM CARE/WAIVER MEDICAL ASSISTANCE APPLICATION
DECLARATION
I swear or affirm, under penalty of perjury, that all information, including financial
information, I have provided on this application is true, correct, and complete to the best
of my knowledge. The requirement to report true, correct, and complete information
includes the requirement to report financial changes that may affect my eligibility for
benefits. Federal and State law requires that I disclose all transfers or gifting of assets
within the 60 month (5 year) period prior to the month of application.
I understand that if I knowingly do not tell the truth, hide information, pretend to be
someone else, or withhold information about myself (and my spouse, if any) or about the
person for whom I am applying (and that person’s spouse, if any), I may be breaking the
law. Information provided on the application may be verified or investigated by Federal,
State, and local officials including Federal and State Quality Control staff.
The consequences of not complying with the law are: my benefits may be denied; I may
be required to pay back the State for benefits received; my case may be investigated for
suspected fraud; and I may be prosecuted for perjury, larceny, and/or Federal health
care fraud [not limited to Statute 42 U.S.C. sec. 1320a-7b(a)(ii)], which may involve a fine
up to $10,000 per offense and/or federal imprisonment.
Signature of Applicant/Recipient
Signature of Witness (If signed with X)
Signature of Spouse (If applicable)
Signature of Authorized Representative (If applicable)
Date
Date
Date
Date
DHR/FIA 9709 (REVISED 7-1-11)
Page 17 of 17
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MARYLAND DEPARTMENT of HUMAN RESOURCES MARYLAND DEPARTMENT of (State of Maryland)

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Completed 14 February 2022

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