STATE OF NEVADA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF WELFARE AND SUPPORTIVE SERVICES
STEVE SISOLAK
Governor
RICHARD WHITLEY, MS
Director
STEVE H. FISHER
Administrator
TANF MEDICAID SNAP
Date:
Case Name:
Case ID:
MEDICAL FACILITY INFORMATION
RE:
(Name) (Date of Birth)
The following information is necessary to determine the Medicaid eligibility for the above-named individual.
Please provide the information below and return to the above address. Your cooperation will help insure integrity and
maintain accountability in the administration of public funds in Nevada. The information provided us will be used only in
conjunction with the official duties of this department and will be considered confidential.
If our identifying information (name and birthdate) does not agree with your records, please indicate the change.
1. Does this person currently reside in your facility?
YES NO
Level of Care:
2. Is this person a County Welfare recipient?
YES NO
If YES, what county?
3. Latest Admission Date: Discharge Date:
4. Current Patient Trust Fund Balance:
$
as of (date)
5. Lowest Patient Trust Fund Balance for the following months:
Months Patient Trust Fund Balance
6. All resources and income (Social Security, pensions, etc.) noted on your records:
Do these checks come to the facility? YES NO
2547 - EG (242.0.0)
Page 1 of 2
