Instructions for Form Dhs 1100b - Supplemental Form for Individuals Applying for Coverage on the Basis of Age, Blindness or Disability and/Or Requests for Long-Term Care Services (Supplement to Form Dhs 1100)

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INSTRUCTIONS
DHS 1100B (Rev. 01/16)
SUPPLEMENTAL FORM FOR INDIVIDUALS APPLYING FOR COVERAGE ON THE BASIS
OF AGE, BLINDNESS OR DISABILITY AND/OR REQUESTS FOR LONG-TERM CARE
SERVICES
(Supplement to Form DHS 1100)
PURPOSE:
In addition to form DHS 1100, “Application for Health Coverage & Help Paying Costs”, the DHS
1100B, “Supplemental Form for Individuals Applying for Coverage on the Basis of Age,
Blindness or Disability and/or Requests for Long-Term Care Services”, shall be completed by
individuals applying for coverage on the basis of age, blindness or disability and/or requests for
Long-Term Care Services.
GENERAL INSTRUCTIONS:
The DHS 1100B, “Supplemental Form for Individuals Applying for Coverage on the
1.
Basis of Age, Blindness or Disability and/or Requests for Long-Term Care Services”,
shall be sent or given to an applicant/beneficiary:
a.
Whose eligibility is determined on the basis of being aged (65 years or older),
blind, or disabled;
b.
Who is requesting LTC services, except Nursing Facility if in an Adult Group; or
c.
Whose application indicated that he/she is blind or disabled and is not eligible to
participate in a MAGI group.
The EW shall fill in all applicable areas using information from the completed application
or eligibility renewal form.
2.
Upon receipt, the supplemental form shall be attached to the DHS 1100 application form,
or the DHS 1100B-2 eligibility renewal form, and filed chronologically with the most
recent information on the top.
3.
An individual shall complete the supplemental form when applying for coverage on the
Basis of Age, Blindness or Disability and/or Requests for Long-Term Care Services.
The applicant/beneficiary shall complete the supplemental form or if applicable, the
community spouse. If the applicant/beneficiary and the community spouse is incapable
of acting on his or her own behalf or is deceased, persons who may complete this form
includes the applicant/beneficiary’s guardian, conservator, or executor, or any other
individual who knows of the applicant/beneficiary’s financial and medical situation.
4.
You may designate an authorized representative by completing Appendix A on page 6.
5.
The supplemental form requests information that is required for an applicant/beneficiary
whose eligibility is being determined on the basis of being aged (65 years or older),
blind, or disabled and to comply with the eligibility requirements for LTC services.
Page 1 of 1
INSTRUCTIONS
DHS 1100B (Rev. 01/16)
SUPPLEMENTAL FORM FOR INDIVIDUALS APPLYING FOR COVERAGE ON THE BASIS
OF AGE, BLINDNESS OR DISABILITY AND/OR REQUESTS FOR LONG-TERM CARE
SERVICES
(Supplement to Form DHS 1100)
PURPOSE:
In addition to form DHS 1100, “Application for Health Coverage & Help Paying Costs”, the DHS
1100B, “Supplemental Form for Individuals Applying for Coverage on the Basis of Age,
Blindness or Disability and/or Requests for Long-Term Care Services”, shall be completed by
individuals applying for coverage on the basis of age, blindness or disability and/or requests for
Long-Term Care Services.
GENERAL INSTRUCTIONS:
The DHS 1100B, “Supplemental Form for Individuals Applying for Coverage on the
1.
Basis of Age, Blindness or Disability and/or Requests for Long-Term Care Services”,
shall be sent or given to an applicant/beneficiary:
a.
Whose eligibility is determined on the basis of being aged (65 years or older),
blind, or disabled;
b.
Who is requesting LTC services, except Nursing Facility if in an Adult Group; or
c.
Whose application indicated that he/she is blind or disabled and is not eligible to
participate in a MAGI group.
The EW shall fill in all applicable areas using information from the completed application
or eligibility renewal form.
2.
Upon receipt, the supplemental form shall be attached to the DHS 1100 application form,
or the DHS 1100B-2 eligibility renewal form, and filed chronologically with the most
recent information on the top.
3.
An individual shall complete the supplemental form when applying for coverage on the
Basis of Age, Blindness or Disability and/or Requests for Long-Term Care Services.
The applicant/beneficiary shall complete the supplemental form or if applicable, the
community spouse. If the applicant/beneficiary and the community spouse is incapable
of acting on his or her own behalf or is deceased, persons who may complete this form
includes the applicant/beneficiary’s guardian, conservator, or executor, or any other
individual who knows of the applicant/beneficiary’s financial and medical situation.
4.
You may designate an authorized representative by completing Appendix A on page 6.
5.
The supplemental form requests information that is required for an applicant/beneficiary
whose eligibility is being determined on the basis of being aged (65 years or older),
blind, or disabled and to comply with the eligibility requirements for LTC services.
Page 1 of 1

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