Form DHR/FIA9709 "Long-Term Care/Waiver Medical Assistance Application" - Maryland

What Is Form DHR/FIA9709?

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

Form Details:

  • Released on July 1, 2011;
  • The latest edition provided by the Maryland Department of Health;
  • 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 Form DHR/FIA9709 by clicking the link below or browse more documents and templates provided by the Maryland Department of Health.

ADVERTISEMENT
ADVERTISEMENT

Download Form DHR/FIA9709 "Long-Term Care/Waiver Medical Assistance Application" - Maryland

Download PDF

Fill PDF online

Rate (4.3 / 5) 8 votes
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
Property tax bill
Condo fees
Rent
Mortgage
Electric bill
Lot Rent
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
Current gross monthly income from all sources
the preceding four years (please include all
including:
forms and schedules). A Record of Account can
VA Pensions
be obtained from the IRS free of charge by
Railroad Retirement
calling 1-800-908-9946 if your Federal tax
Pensions
returns cannot be located.
Annuities
Bank and Financial statements on all accounts
Face and cash value of Life Insurance policies
owned and co-owned:
(current annual statement)
Current Month (month of application)
Current statement for burial accounts
Previous Month (month prior to
Burial Plot Deeds
application)
Life Estate Deeds
The last five years of the anniversary
Promissory Notes
month of the application
Mortgage Notes and Mortgage Deeds
Current statement of retirement accounts
Trusts (including appendices, schedules,
Current statement of IRA or Keogh Accounts
annual accountings, and amendments for the
Current statements of:
past five years)
Stocks
Private Health Insurance Cards including
Bonds
Medicare (copy of both sides)
Money Market Funds
Health Insurance premium amounts
Mutual Funds, Treasury, or Other Notes
Power of Attorney or Legal Guardianship
Certificates
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)
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
Property tax bill
Condo fees
Rent
Mortgage
Electric bill
Lot Rent
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
Current gross monthly income from all sources
the preceding four years (please include all
including:
forms and schedules). A Record of Account can
VA Pensions
be obtained from the IRS free of charge by
Railroad Retirement
calling 1-800-908-9946 if your Federal tax
Pensions
returns cannot be located.
Annuities
Bank and Financial statements on all accounts
Face and cash value of Life Insurance policies
owned and co-owned:
(current annual statement)
Current Month (month of application)
Current statement for burial accounts
Previous Month (month prior to
Burial Plot Deeds
application)
Life Estate Deeds
The last five years of the anniversary
Promissory Notes
month of the application
Mortgage Notes and Mortgage Deeds
Current statement of retirement accounts
Trusts (including appendices, schedules,
Current statement of IRA or Keogh Accounts
annual accountings, and amendments for the
Current statements of:
past five years)
Stocks
Private Health Insurance Cards including
Bonds
Medicare (copy of both sides)
Money Market Funds
Health Insurance premium amounts
Mutual Funds, Treasury, or Other Notes
Power of Attorney or Legal Guardianship
Certificates
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
LDSS Office
Programs Applied For or
Assistance Unit IDs
Receiving
Client ID
FOR WORKER
Worker’s Name
USE ONLY
Application Date
This part is for our
staff. Please continue
to Section A.
_______________________
__________________
Program Medical Coverage Group
AU ID
SECTION A – BENEFIT SELECTION: Please tell us about which benefits you want and which
benefits you already have.
Do you need Medical Assistance for medical bills incurred in the
I am applying for:
past 3 months?
Long-Term Care
If yes, you will need to provide copies of the bills to your case manager.
Waiver
YES
NO
Medical Assistance
ID # ________________________________________________________________
Tell us if you are
If you already receive Medical Assistance, please provide your ID number.
currently receiving
Cash Assistance
other assistance.
Food Stamps
I currently
, list: _______________________________________________________________
Other
receive:
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:
Additional Social Security Number:
If you have a Social Security Number, enter it here.
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
Race
1 – American Indian/Alaskan Native
Optional
Optional –
1 – Hispanic or Latino
2 – Asian
Please choose
3 – Black/African American
all race codes
2 – Not Hispanic or Latino
4 – Native Hawaiian/Pacific Islander
that apply to you.
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
If yes, please list the state:
(Medicaid) benefits from another state?
_______________________________________________
Are you a U.S. Citizen?
YES
NO
What is your primary language?
If you answered NO, please complete SECTION C –
_______________________________________________
IMMIGRATION STATUS, below
.
Do you need an interpreter?
YES
NO
If you 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
On what date did you receive
Are you a Sponsored
What is your Country of
Status?
your INS Status?
Immigrant?
Origin?
_______________________
______/_______/_______
YES
NO
_____________________
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
What is your home address or the address of your facility?
name of the facility?
Street _______________________________________________________________
__________________________
City __________________________ State ____________ ZIP ________________
On what date did you enter the
facility?
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)
Do you (applicant/recipient) intend
intend to return home?
YES
NO
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 _____________________________________________________________________
Did you or your spouse own
this home?
City ___________________________ State ___________ ZIP ______________________
YES
NO
Street _____________________________________________________________________
Did you or your spouse own
this home?
City ___________________________ State ___________ ZIP ______________________
YES
NO
Street _____________________________________________________________________
Did you or your spouse own
this home?
City ___________________________ State ___________ ZIP ______________________
YES
NO
Street _____________________________________________________________________
Did you or your spouse own
this home?
City ___________________________ State ___________ ZIP ______________________
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