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Maryland Dhr Template in PDF

The Maryland Department of Resources form, specifically titled as Long-Term Care/Waiver Medical Assistance Application, acts as a crucial document for individuals seeking assistance for long-term care or waiver applications within the state. It compiles a comprehensive checklist and provides a structured application process to facilitate individuals and their families in applying for medical assistance. Detailing necessary documents and step-by-step instructions, this form is pivotal in ensuring the eligibility and successful application for long-term care benefits. To begin the application process or to learn more, click the button below.

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The Maryland Department of Human Resources, in coordination with the Department of Health and Mental Hygiene, provides a crucial pathway for residents seeking Long-Term Care/Waiver Medical Assistance through their comprehensive application process. This form serves as a comprehensive checklist and guide for applicants navigating the intricacies of applying for long-term care or waivers. Required documentation includes proof of financial resources, income, property ownership, and other assets which may affect eligibility. It emphasizes the importance of applying early and provides detailed instructions on the necessary steps and documents required, such as federal tax returns, bank statements, insurance policies, and proof of income, among others. With a clear stipulation for applicants to submit copies rather than original documents, the form caters to protecting individuals' personal and sensitive information. Additionally, it outlines the process for those who already receive medical assistance and those applying for the first time, ensuring that every category of applicant is guided properly through the application stages. This proactive approach by the Maryland Department of Human Resources and Department of Health and Mental Hygiene illustrates a commitment to accessible healthcare for its residents, particularly for long-term care and waiver services, by simplifying the application process and providing comprehensive support documentation.

Sample - Maryland Dhr Form

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 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)

MARYLAND DEPARTMENT OF HUMAN RESOURCES MARYLAND

DEPARTMENT OF HEALTH AND MENTAL HYGIENE LONG-TERM

CARE/WAIVER MEDICAL ASSISTANCE APPLICATION

Date Signed Application

Received in Local Department

MUST BE DATE STAMPED

FOR WORKER

USE ONLY

This part is for our

staff. Please continue

to Section A.

LDSS Office	Programs Applied For or		Assistance Unit IDs
	Receiving		Client ID

Worker’s Name

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.

Icurrently 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:

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

Optional

	Race	1 – American Indian/Alaskan Native
1 – Hispanic or Latino	Optional –	2 – Asian
	Please choose	3 – Black/African American
	all race codes	3 – Black/African American
2 – Not Hispanic or Latino	all race codes	4 – Native Hawaiian/Pacific Islander
2 – Not Hispanic or Latino	that apply to you.	4 – Native Hawaiian/Pacific Islander
	that apply to you.	5 – White
		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

Marital Status

Single

Married

Divorced

Separated

Widowed

Are you receiving Medical Assistance (Medicaid) benefits from another state?

YES

NO	If yes, please list the state:

Are you a U.S. Citizen?

YES NO

If you answered NO, please complete SECTION C – IMMIGRATION STATUS, below.

What is your primary language?

Do you need an interpreter?

YES

If you are not registered to vote,

would you like to receive a voter registration form?

YES

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

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

Do you (applicant/recipient) intend to return home within 6 months?

YES

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

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

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 Authorized 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

Street

Do you or your spouse own

this home?

City

State

_ ZIP

YES NO

Telephone #

SECTION H – DISABILITY: Please tell us about your disability, if you have one.

Are you disabled?

If yes, when did the disability begin?

YES

What is your disability?

				Premium Amount
Do you receive Medicare Part A?	YES	NO	$
Do you receive Medicare Part B?	YES	NO	$
Do you receive Medicare Part B?	YES	NO	$		SEND PROOF	Please send
					verification of the premium
Do you receive Medicare Part C?	YES	NO	$		amounts you pay
Do you receive Medicare Part D?	YES	NO	$
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

Veteran’s Status

Military 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 Local

Union Name

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

Gross Wages per Pay Period, including tips and

Began_

Ended_

commissions.

per

Hours per Pay Period

How often do you get

If the job has ended, what is your last expected pay date?

paid?

Weekly

Biweekly

Monthly

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	RECEIVING INCOME			AMOUNT	APPLICATION		APPLICATION DATE OR
OR INCOME	OR BENEFITS?			AMOUNT		STATUS	DENIAL DATE
OR INCOME	OR BENEFITS?					STATUS	DENIAL DATE
Social Security
Please write your claim number:	YES	NO	$			Applied for
	YES	NO	$			Denied
						Denied

Black Lung Benefits	YES	NO	$			Applied for
Black Lung Benefits	YES	NO	$			Denied
						Denied
SSI (Supplemental Security
Income)						Applied for
Please write your claim number:	YES	NO	$			Applied for
Please write your claim number:	YES	NO	$			Denied
						Denied

Veteran’s Pension/Benefits	YES	NO	$			Applied for
Veteran’s Pension/Benefits	YES	NO	$			Denied
						Denied
Pension or Retirement	YES	NO	$			Applied for
Pension or Retirement	YES	NO	$			Denied
						Denied
Civil Service Annuity	YES	NO	$			Applied for
Civil Service Annuity	YES	NO	$			Denied
						Denied
Railroad Retirement Benefits
Please write your claim number:	YES	NO	$			Applied for
	YES	NO	$			Denied
						Denied

Alimony	YES	NO	$			Applied for
Alimony	YES	NO	$			Denied
						Denied
DHR/FIA 9709 (REVISED 7-1-11)							Page 6 of 17

SECTION L – YOUR BENEFITS AND OTHER INCOME (continued)


TYPE OF BENEFIT	RECEIVING INCOME			AMOUNT	APPLICATION	APPLICATION DATE OR
OR INCOME	OR BENEFITS?			AMOUNT	STATUS	DENIAL DATE
OR INCOME	OR BENEFITS?				STATUS	DENIAL DATE
Worker’s Compensation	YES	NO	$		Applied for
Worker’s Compensation	YES	NO	$		Denied
					Denied
Disability/Sick Benefits	YES	NO	$		Applied for
Disability/Sick Benefits	YES	NO	$		Denied
					Denied
Union Benefits	YES	NO	$		Applied for
Union Benefits	YES	NO	$		Denied
					Denied
Unemployment Benefits	YES	NO	$		Applied for
Unemployment Benefits	YES	NO	$		Denied
					Denied
Lump Sum Cash Amounts	YES	NO	$		Applied for
Lump Sum Cash Amounts	YES	NO	$		Denied
					Denied
Interest/Dividends from Stocks,					Applied for
Bonds, Savings, or other	YES	NO	$		Applied for
Bonds, Savings, or other	YES	NO	$		Denied
investments					Denied
investments
Business Income	YES	NO	$		Applied for
Business Income	YES	NO	$		Denied
					Denied
Other (e.g., Rental Income, or					Applied for
Compensation from a Legal	YES	NO	$		Applied for
Compensation from a Legal	YES	NO	$		Denied
Settlement)					Denied
Settlement)
Other					Applied for
Please describe:	YES	NO	$		Applied for
Please describe:	YES	NO	$		Denied
					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		$
Cash on Hand	NO		$
	NO

Checking Account	YES		$
Checking Account	NO		$
	NO

Savings Account	YES		$
Savings Account	NO		$
	NO

Credit Union Account	YES		$
Credit Union Account	NO		$
	NO

Trust Fund	YES		$
Trust Fund	NO		$
	NO

IRA or Keogh	YES		$
Account	NO		$
Account	NO

Other Retirement	YES		$
Accounts	NO		$
Accounts	NO

Stocks and Bonds	YES		$
Stocks and Bonds	NO		$
	NO

DHR/FIA 9709 (REVISED 7-1-11)					Page 7 of 17

SECTION M – ASSETS (continued)

	ASSET TYPE	CHECK ONE	OWNER	AMOUNT	ACCOUNT NUMBER	INSTITUTION NAME

Treasury or Other		YES		$
Notes		NO		$
Notes		NO

Annuity		YES		$
Annuity		NO		$
		NO

Ownership in a		YES		$
Company		NO		$
Company		NO

Patient Fund Account		YES		$
Patient Fund Account		NO		$
		NO

Other		YES		$
		NO		$
		NO

Other		YES		$
		NO		$
		NO

Other		YES		$
		NO		$
		NO

Other		YES		$
		NO		$
		NO

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

↓ Maryland Dhr PDF Form

Document Data

#	Fact
1	Form is designed for Long-Term Care/Waiver Medical Assistance applications in Maryland.
2	Applicants are required to provide extensive financial documentation for the current and preceding four years.
3	Documents focused on include assets transfer, tax returns, bank statements, retirement accounts, and life insurance policies among others.
4	Asset disposal or transfer within the past 5 years needs detailed documentation, including value and recipient.
5	Applicants should apply as soon as possible and can submit additional documents later if not initially available.
6	Governing bodies mentioned are the Maryland Department of Human Resources and Maryland Department of Health and Mental Hygiene.
7	Form also inquires about personal information such as marital status, citizenship status, and residency in Maryland.
8	Immigration status and relevant documentation are required for non-citizen applicants.
9	Governed under Maryland state laws and designed to comply with Title VI of the Civil Rights Act of 1964 for non-discrimination.

How to Write Maryland Dhr

After receiving the Maryland Department of Human Services and Department of Health and Mental Hygiene Long-Term Care/Waiver Medical Assistance Application, individuals are ready to proceed with the next steps. Completing and submitting this application is crucial for those in need of long-term care or waiver services. The documentation required supports the application process by providing essential information about the applicant's financial situation, residency, and need for assistance.

To ensure a smooth application process, follow these detailed steps:

Begin by reviewing the "Check List of Items Needed for Your Long-Term Care / Waiver Application" on the first page. Gather as many of the listed documents as you can to include with your application.
Enter the current date at the top of the application where it states "Date Signed".
Proceed to Section A – BENEFIT SELECTION. Indicate which benefits you are applying for by checking the appropriate box for Long-Term Care, Waiver, or both. If you have incurred medical bills in the past 3 months, indicate "YES" and note that you will need to provide copies of these bills.
In the section about currently receiving assistance, if applicable, list any benefits you currently receive (Medical Assistance ID number, Cash Assistance, Food Stamps, etc.).
In Section B – APPLICANT INFORMATION, fill out your personal information including your name, social security number(s), date of birth, gender, and if optional, your ethnicity and race.
Answer questions about your residency in Maryland, marital status, whether you are receiving benefits from another state, your citizenship, primary language, need for an interpreter, and voter registration status.
If you are not a U.S. citizen, complete SECTION C – IMMIGRATION STATUS with information about your immigration status, including a copy of the front and back of your INS card.
For SECTION D – CURRENT ADDRESS of HOME or INSTITUTION/LONG-TERM CARE FACILITY, provide information about your current living situation, whether it's a long-term care facility or a home address.
In SECTION E – PREVIOUS ADDRESSES, list where you have lived in the past five years, including whether you or your spouse owned the home.
If you would like to authorize someone to represent you in this application process, complete SECTION F – AUTHORIZED REPRESENTATIVE with your representative's full name, address, and contact information.
Review your application thoroughly to ensure all information is accurate and complete. Attach any additional documents or information needed on separate sheets.
Send your completed application along with the evidence and documents you've gathered to the address provided by the Maryland Department of Health and Mental Hygiene. Remember to keep copies of all documents for your records.

By following these steps, applicants can ensure their application is completed accurately and submitted properly, allowing for a smoother review process. It is important to apply as early as possible and provide as much information and as many documents as you can to support your application.

Understanding Maryland Dhr

What is the Maryland DHR Form?

The Maryland DHR Form, officially known as the Maryland Department of Human Resources Long-Term Care/Waiver Medical Assistance Application, is a document used to apply for Long-Term Care Medical Assistance. This assistance is designed for individuals who require long-term care in a facility or through a waiver program for at-home care.

Who needs to complete the Maryland DHR Form?

Individuals seeking Long-Term Care Medical Assistance in the state of Maryland must complete this form. This includes those who are applying for assistance with long-term care services in a facility or those looking for waiver services to receive care in their own home.

What documents do I need to submit with my application?

When submitting your application, include as many of the following items as possible:

Federal Tax Returns for the current and preceding four years.
Bank and financial statements.
Proof of income.
Details of assets disposed of in the last 5 years.
Proof of insurance and premiums.
Legal documents like Power of Attorney, if applicable.

Make sure to send copies of these documents, not the originals.

What if I don't have all the required documents at the time of application?

It's important to apply as soon as possible, even if you don't have all the required documents. Submit whatever documents you have on hand with your application. The Department will provide additional time for you to submit any missing documents.

How do I report assets that have been sold, traded, gifted, or disposed of?

For assets that have been disposed of in the last 5 years, you must provide the type of asset, reason for transfer, value of the asset, who received the asset, and the amount received for the asset.

Can my spouse keep some of my monthly income?

If you are interested in having your spouse keep part of your monthly income, please provide your spouse’s gross monthly income, along with your property tax bill, condo fees, rent, mortgage, electric bill, and lot rent.

What happens after I submit my application?

After your application is submitted, it will be reviewed by the Department. They may request additional documentation if needed. The review process will determine your eligibility for the Long-Term Care Medical Assistance program.

Do I need to be a Maryland resident to apply?

Yes, you need to be a resident of Maryland to apply for Long-Term Care Medical Assistance using this form.

Where can I get help with completing the Maryland DHR Form?

If you need assistance with the application process, you may contact your local Department of Social Services office. Additionally, legal guardians or those with Power of Attorney for an individual can apply on their behalf.

Common mistakes

Not providing complete information about asset transfers: Many people forget or misunderstand the requirement to provide detailed information about the disposal of assets, such as property, motor vehicles, stocks, or cash, in the five years prior to applying. This includes failing to mention the type of asset, reason for transfer, value of the asset, who received it, and the amount received. This oversight can delay the application process or affect eligibility.
Waiting to apply until after gathering all documents: A common mistake is delaying the application until all necessary documents are collected. The instructions clearly state to apply as soon as possible and to send any documents currently available, with the opportunity to submit additional information later. This mistake can cause unnecessary delays in receiving benefits.
Omitting financial information: Applicants often overlook the necessity to submit comprehensive financial records. This includes the current month and the previous month's bank statements, the last five years of statements for the month of the application anniversary, retirement accounts, IRAs, Keogh Accounts, stocks, bonds, and other financial assets. Failing to provide these documents in the initial application can significantly slow down the review process.
Failure to indicate other benefits received: Another mistake is not indicating whether the applicant or their spouse is currently receiving other types of assistance, such as Medical Assistance, Cash Assistance, Food Stamps, etc. This information helps in the determination process for eligibility and the type of assistance they qualify for, impacting the speed and outcome of the application.

Documents used along the form

When applying for Long-Term Care/Waiver Medical Assistance in Maryland, applicants often need to compile and submit a variety of supporting documents to ensure a comprehensive review of their eligibility. The Maryland Department of Human Resources (DHR) and the Maryland Department of Health and Mental Hygiene request these documents to accurately assess the applicant's financial situation and care needs.

Proof of Identity and Citizenship: Documentation such as a birth certificate or passport is required to prove the applicant's identity and citizenship or legal residence status in the United States. This is vital for verifying eligibility for state-supported assistance programs.
Proof of Residence: Utility bills, a lease agreement, or mortgage statements serve as proof of Maryland residency. These documents help establish that the applicant lives in the jurisdiction where they are applying for assistance.
Income Verification: Pay stubs, Social Security benefit statements, or other income verification documents are needed to determine the applicant's financial situation. These documents support the application process by providing a clear picture of the applicant's ability to contribute to their care costs.
Asset Documentation: Bank statements, property deeds, vehicle registration, or information on other assets prove the applicant's financial resources. This information is crucial for determining eligibility based on the financial criteria set forth by the Medicaid program.
Medical Records: Health records, including doctor's notes, hospital discharge summaries, and medication lists, may be requested to establish the level of care required. These documents assist case workers in making informed decisions regarding the necessity and type of services needed.
Insurance Policies: Information on existing health insurance policies, including Medicare or private health insurance, helps determine how medical services will be paid for and how Medicaid can assist.

Gathering these documents in advance can streamline the application process for Long-Term Care/Waiver Medical Assistance. By providing a complete and accurate picture of their situation, applicants can help ensure a smoother review process and a quicker determination regarding their eligibility for assistance.

Similar forms

The Maryland DHR form is similar to other documents used in the application for various benefits and services, providing a structured format for collecting necessary personal information, financial details, and supporting documentation. Each similar document exhibits specific features tailored to its purpose, yet the core objective aligns with the DHR form in facilitating access to certain benefits or services. These similarities can be observed across forms for public assistance, health insurance applications, and eligibility determination for social services, each requiring a detailed account of an applicant's financial status, household composition, and other relevant information.

Form SSA-8000: Application for Supplemental Security Income (SSI)

This form, used by the Social Security Administration, resembles the Maryland DHR form in several ways. Both require detailed personal information, including social security numbers and household makeup. They also necessitate a comprehensive listing of financial assets, income sources, and living arrangements, aiming to assess eligibility for benefits. However, the SSA-8000 form focuses specifically on determining eligibility for Supplemental Security Income, a federal program providing financial assistance to eligible individuals who are elderly, blind, or disabled.

Health Insurance Marketplace Application

Similar to the Maryland DHR form, the Health Insurance Marketplace application seeks detailed information on household composition, income, and current health insurance status to determine eligibility for health insurance plans under the Affordable Care Act, including potential subsidies or Medicaid. Both forms serve as a gateway to securing essential services—health coverage in the case of the Marketplace application, and long-term care or waiver medical assistance with the DHR form. The emphasis on financial and healthcare needs underscores their purpose in facilitating access to vital resources.

Application for Public Housing Assistance

Public housing assistance applications share commonalities with the Maryland DHR form, especially regarding the collection of data on household size, income, assets, and employment status to determine eligibility for housing benefits. Like the DHR form, these applications aim to support individuals and families in need by providing access to essential services—in this case, affordable housing. Both incorporate checks on financial well-being and require applicants to disclose detailed personal and financial information to ensure assistance is appropriately allocated.

Dos and Don'ts

When completing the Maryland Department of Human Resources (DHR) form for Long-Term Care / Waiver Medical Assistance, it's important to approach the process with care and attention. Below are key guidelines to follow – some actions to do and others to avoid – to ensure the application process is smooth and successful.

Do gather all necessary documentation before starting. This includes federal tax returns, bank statements, and proof of income, among others listed in the application instructions.
Don't wait to apply. Submit the application with any documents you currently have; you can send additional information later if needed.
Do send copies, not originals. To avoid losing important documents, only send copies unless specifically requested to provide originals.
Don't overlook the details about asset transfers in the past five years. Accurately provide information regarding the type, value, and recipient of assets.
Do include information about your spouse if applicable. This includes gross monthly income and expenses, which can affect your eligibility.
Don't leave any section incomplete. Answer every question, and attach additional sheets if more space is required.
Do review your application for accuracy. Before submitting, double-check all entries for completeness and correctness.
Don't hesitate to ask for help. If there's something you don't understand, contact the DHR for assistance or consider involving an authorized representative.
Do consider your privacy. When providing sensitive information, ensure it's done securely to protect your personal data.

Following these guidelines will help ensure that your application is filled out correctly and processed in a timely manner, moving you closer to receiving the assistance you need.

Misconceptions

When people think about applying for Long-Term Care/Waiver Medical Assistance in Maryland, several misconceptions can create confusion and anxiety. Here are five common misunderstandings about the Maryland DHR form and the truths behind them:

Misconception 1: You must wait to apply until you have all the required documents.

This is not the case. The form clearly states, "Do not wait to apply." It's better to submit your application with any documents you have. The department will give you more time to provide any additional documents required. This approach helps to start the process quicker, ensuring you or your loved ones receive the necessary help sooner.

Misconception 2: You need to send original documents with your application.

Applicants are advised to send copies, not originals. This precaution ensures that your original documents remain with you, safe from loss or damage. The department requests copies to process your application while keeping your valuable documents secure with you.

Misconception 3: If you apply, your spouse will lose their income.

Many people worry that applying for Long-Term Care Medical Assistance will negatively affect their spouse's income. However, the department asks for information on the spouse’s income to determine if they can keep some of it. The application process is designed to assess your needs without unduly impacting your spouse's financial security.

Misconception 4: The form is only for those applying for Long-Term Care benefits for the first time.

The checklist and form serve not only new applicants but also those who might be reapplying or updating their application. It provides a thorough list of documents needed whether you are applying for the first time or need to reevaluate your assistance package.

Misconception 5: Non-citizens cannot apply for Long-Term Care/Waiver Medical Assistance.

While the application does ask for citizenship status, it also provides a section for non-citizens to fill out their immigration status. This inclusion means that non-citizens are eligible to apply for assistance, and the process accommodates a wide range of applicants, reflecting the diverse needs of Maryland’s residents.

Understanding the realities behind these misconceptions can make the application process for Maryland’s Long-Term Care/Waiver Medical Assistance seem less daunting. It encourages prospective applicants to take the necessary steps towards receiving the care and support they or their loved ones need.

Key takeaways

When filling out and using the Maryland Department of Human Resources (DHR) Long-Term Care/Waiver Medical Assistance Application, there are key points to remember to ensure the process is conducted smoothly and effectively. Here are critical takeaways:

The application requires detailed information about the applicant's financial situation, including assets transferred in the past five years. This information is crucial for determining eligibility for Long-Term Care Medical Assistance.
Applicants should submit copies of requested documents, not originals, to avoid losing important personal documents. However, maintaining personal copies for records is advised.
It is important to apply as soon as possible, even if not all documents are currently available. Submitting available documents with the application does not hinder the process, as there will be an opportunity to provide additional documents later.
Documentation of both the applicant's and their spouse's income and resources is necessary for a complete review process. This includes federal tax returns, bank statements, retirement accounts, and other financial documents spanning the current month back to the last five years.
Proof of other types of income or assets, such as VA pensions, annuities, life insurance policies, burial accounts, and health insurance cards, must also be provided.
Legal documents like Power of Attorney or Legal Guardianship Documents should be submitted if applicable, ensuring that all necessary legal permissions are in place for the application to be processed effectively.
The form requests information regarding the applicant's ethnicity and race. While providing this information is optional, it aids in demonstrating compliance with Federal Civil Rights Law and will not affect the eligibility determination process.
Citizenship or immigration status may require additional documentation. For non-citizens, photocopies of both sides of the INS card are necessary to demonstrate legal status in the United States.

Understanding these key points before beginning the application for Long-Term Care/Waiver Medical Assistance in Maryland helps streamline the process, ensuring that applicants provide all necessary information and documentation to support their application effectively.

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