DHHS Form 3400-B "Additional Information for Nursing Home and in-Home Care" - South Carolina

What Is DHHS Form 3400-B?

This is a legal form that was released by the South Carolina Department of Health and Human Services - a government authority operating within South Carolina. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on December 1, 2020;
  • The latest edition provided by the South Carolina Department of Health and Human Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of DHHS Form 3400-B by clicking the link below or browse more documents and templates provided by the South Carolina Department of Health and Human Services.

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Download DHHS Form 3400-B "Additional Information for Nursing Home and in-Home Care" - South Carolina

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Additional Information for
Nursing Home and In-Home Care
Nursing Home
In-Home Care
This form is used to gather other information needed to make a decision about eligibility
for Nursing Home, Institutional or In-Home Care. Please answer the following questions as
completely as possible as they apply to the person who is applying and their spouse. If you
are applying on behalf of someone else, enter your name as the Authorized Representative.
The rights and responsibilities you agreed to on the original application are still in effect. If you
have questions, please contact Healthy Connections at (888) 549-0820 (TTY 1-888-842-3620).
We may ask for additional information or documentation to establish your eligibility.
Name of person needing assistance (First, Middle, Last)
Social Security Number
Medicaid ID
Date of Birth (mm/dd/yyyy)
Authorized Representative (if applicable):
Relationship to Applicant
I. Statement of Transfers
1. In the past five years have you:
Yes
No
Closed a Bank Account
Closed an Investment Account
Closed a Retirement Account
Transferred Life-Estate Interest In Your Home or Any Other Property
If YES, fill in the following values, if known:
Accounts
Account
Date Closed Closing Balance
Account
Date Closed Closing Balance
$
$
Account
Date Closed Closing Balance
Account
Date Closed Closing Balance
$
$
Life Estate Interest
Property
Transfer Date Appraised Value
Property
Transfer Date Appraised Value
$
$
2. In the past five years have you sold or given away your home?
Yes
No
If YES, fill in the following, if known:
Appraised Value
Sale Price
$
$
3. In the past five years have you sold or given away other real estate?
Yes
No
If YES, fill in the following values, if known:
Property
Appraised Value Sale Price
Property
Appraised Value Sale Price
$
$
$
$
Property
Appraised Value Sale Price
$
$
TOTAL
$
$
DHHS Form 3400-B (Dec. 2020)
Page 1 of 5
Additional Information for
Nursing Home and In-Home Care
Nursing Home
In-Home Care
This form is used to gather other information needed to make a decision about eligibility
for Nursing Home, Institutional or In-Home Care. Please answer the following questions as
completely as possible as they apply to the person who is applying and their spouse. If you
are applying on behalf of someone else, enter your name as the Authorized Representative.
The rights and responsibilities you agreed to on the original application are still in effect. If you
have questions, please contact Healthy Connections at (888) 549-0820 (TTY 1-888-842-3620).
We may ask for additional information or documentation to establish your eligibility.
Name of person needing assistance (First, Middle, Last)
Social Security Number
Medicaid ID
Date of Birth (mm/dd/yyyy)
Authorized Representative (if applicable):
Relationship to Applicant
I. Statement of Transfers
1. In the past five years have you:
Yes
No
Closed a Bank Account
Closed an Investment Account
Closed a Retirement Account
Transferred Life-Estate Interest In Your Home or Any Other Property
If YES, fill in the following values, if known:
Accounts
Account
Date Closed Closing Balance
Account
Date Closed Closing Balance
$
$
Account
Date Closed Closing Balance
Account
Date Closed Closing Balance
$
$
Life Estate Interest
Property
Transfer Date Appraised Value
Property
Transfer Date Appraised Value
$
$
2. In the past five years have you sold or given away your home?
Yes
No
If YES, fill in the following, if known:
Appraised Value
Sale Price
$
$
3. In the past five years have you sold or given away other real estate?
Yes
No
If YES, fill in the following values, if known:
Property
Appraised Value Sale Price
Property
Appraised Value Sale Price
$
$
$
$
Property
Appraised Value Sale Price
$
$
TOTAL
$
$
DHHS Form 3400-B (Dec. 2020)
Page 1 of 5
4. In the past five years have you sold or given away any motor vehicles,
Yes
No
boats, or other recreational vehicle?
If YES, fill in the following values, if known:
Vehicle
Appraised Value Sale Price
Vehicle
Appraised Value Sale Price
$
$
$
$
Vehicle
Appraised Value Sale Price
$
$
TOTAL
$
$
5. In the past five years have you given away cash?
Yes
No
If YES:
Person to whom it was given
Date given
Amount
$
$
CLTC Worker (If Applicable) (Print)
CLTC Worker Signature
Date
II. Additional Information
6. Please check if anyone has Conservatorship, Guardianship, or Power of Attorney for the
applicant. If yes, please enclose a copy of the legal papers.
Conservatorship
Name:
Phone
Guardianship
Name:
Phone
Power of Attorney
Name:
Phone
7. Where is the applicant right now?
Home
Hospital
Nursing Home
Other
If not at home, tell us where the applicant is:
Name of facility:
Date entered facility:
Did the applicant live at home at any time during the month he/she entered
the nursing facility?
Yes
No
8. Where has the applicant lived in the past five (5) years?
Street Address
City
County
State
From (date) To (date)
DHHS Form 3400-B (Dec. 2020)
Page 2 of 5
9. If married and entering a nursing home, does the applicant want to give
Yes
No
(allocate) part or all of income to a spouse remaining at home?
10. Does the applicant want to give (allocate) income to dependent adults living
in the home or to dependent children?
Yes
No
11. Does anyone in the applicant’s home (including the applicant or applicant’s
spouse, children or dependent adults) receive or has anyone applied for
Yes
No
any other income?
Before we can make a decision on your application, you may have to give us proof of income for
the past 4 weeks. In addition to the income you listed on your application, do you have any of
the following? If YES, check all boxes that apply and complete the table below.
Supplemental Security Income (SSI)
Child support
Disability benefits
Veterans Administration (VA) benefits
Military Allotments
Other
Federal Retirement (Civil Service, FERS)
Money from friends or relatives
Land contract, mortgage or other notes payable to a household member.
(Please provide a copy of the contract, mortgage, note or other agreement.)
Person receiving/expecting money
Income source/type How often received Amount received
$
$
$
$
12. Has the applicant or spouse ever worked somewhere that has a retirement
benefit, military retirement or VA benefit for which he or she may be
Yes
No
eligible to receive money?
If YES, who was working?
Where?
For how long?
13. Has the applicant received an inheritance in the last five years?
Yes
No
If YES, from whom?
Date of Death:
State/County where estate was probated
Additional Inheritance
If YES, from whom?
Date of Death:
State/County where estate was probated
DHHS Form 3400-B (Dec. 2020)
Page 3 of 5
14. Do you or your spouse own any property? (Include property in other states.) If
Yes
No
YES, check the boxes that apply and tell us about the property.
Home (house, buildings and land where you live)
Land (not connected to current home)
Other House or Building (not your home)
Vacation Home or Time Share Property
a. What is the address/location of the property?
b. What is the address/location of other property?
(List home property first)
Owner’s Name:
Owner’s Name:
Is 14-a your Home Property or Primary Residence where you currently live or where you want to return to
Yes
No
live if you are living somewhere else?
15. Please check the box beside any of the items that the applicant, applicant’s spouse or
applicant’s dependent(s) owns or are buying. Tell us about it in the table below.
Bank Checking Account
Bank Savings Account
Car, Truck, Van
Certificate of Deposit
Motorcycle, Boat, Camper
Annuity
(provide a copy)
Trust Fund or Trust Account
Pre-Need Burial Contract
Cash on Hand
Money Set Aside for Burial
Cemetery Burial Space
Life Insurance
401k, IRA, or Retirement Account
Stocks, Bonds, Mutual Funds
Farm Machinery or Business
DirectExpress Debit Card for SSA, SSI
Yes
No
Equipment
or other benefits
Other:
Tell Us About the Asset
Include the name of bank or funeral home and
Current Value
any account numbers or other information used
or Balance
Owned by
to identify the asset.
$
$
$
$
$
$
$
NOTE: When you return this form, you must send proof of these assets or resources, including
any supporting documents. You will be asked to send information for the month of
application and at least three months prior to the application month.
DHHS Form 3400-B (Dec. 2020)
Page 4 of 5
16. If ever married, give the following information about the applicant’s spouse(s).
Never been married
Name of most recent spouse:
Living
In a medical facility
Separated: When or How Long?
Married, living together
Divorced
Married, living apart
Current Street Address
City
State
ZIP
Phone
Deceased - Date of Death:
State/County where estate was probated
Name of most recent spouse:
Living
In a medical facility
Separated: When or How Long?
Married, living together
Divorced
Married, living apart
Current Street Address
City
State
ZIP
Phone
Deceased - Date of Death:
State/County where estate was probated
ESTATE RECOVERY
(BE SURE TO GET A COPY OF THE ESTATE RECOVERY BROCHURE)
As an applicant/beneficiary for Medicaid services, I understand that there are two groups of
people that are affected by estate recovery:
A person of any age who was a patient in a nursing facility, intermediate care facility
for the intellectually disabled, or other medical institution at the time of death, and
who was required to pay most of his/her income for the cost of care; or
A person who was 55 years of age or older when he/she received medical assistance
consisting of nursing facility services, home and community based services, and
hospital and prescription drug services provided to individuals in nursing facilities or
receiving home community-based services.
I understand that upon receiving any of these services, the Department of Health and Human
Services may file a claim against my estate (all personal and real property owned by me at my
death) for the amount Medicaid has paid for my services.
Applicant or Authorized Representative’s Signature Date
Mail to: SCDHHS-Central Mail
PO Box 100101
Columbia, SC 29202-3101
DHHS Form 3400-B (Dec. 2020)
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