Printable Maryland Dhr Template

The Maryland DHR form is an essential application for individuals seeking Long-Term Care or Waiver Medical Assistance in Maryland. This form outlines the necessary documentation required to determine eligibility and streamline the application process. Timely submission of this form is crucial, as it can significantly impact your access to needed services and support.

To ensure your application is processed efficiently, please fill out the form by clicking the button below.

Open Maryland Dhr Editor

Navigation

The Maryland Department of Human Resources (DHR) and the Maryland Department of Health and Mental Hygiene have established a comprehensive application process for individuals seeking Long-Term Care or Waiver Medical Assistance. This application, known as the Maryland DHR form, is designed to gather essential information to determine eligibility for these critical services. Applicants are required to submit a variety of documents, including proof of income, bank statements, and details regarding any assets transferred in the past five years. It is crucial to act promptly; individuals are encouraged to apply without delay, even if they do not have all required documents at the time of submission. The application form includes sections that require detailed personal information, such as marital status, residency, and citizenship status, as well as inquiries into any existing medical assistance benefits. Furthermore, applicants must disclose their current living situation, whether in a long-term care facility or at home, and provide a history of their addresses over the past five years. Completing this application accurately and thoroughly is vital for ensuring that individuals receive the assistance they need in a timely manner.

Maryland Dhr Preview

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

Click for Maryland Dhr File

Form Attributes

Fact Name	Details
Governing Law	The Maryland Long-Term Care/Waiver Medical Assistance Application is governed by the Maryland Medicaid regulations under the Code of Maryland Regulations (COMAR) Title 10, Subtitle 09.
Application Purpose	This application is designed for individuals seeking Long-Term Care Medical Assistance or Waiver services.
Proof of Income	Applicants must provide proof of income, including Federal Tax Returns for the current and preceding four years.
Asset Disclosure	Information regarding any assets sold, traded, or gifted in the past five years must be disclosed, including the type and value of each asset.
Document Submission	Applicants are advised to send copies of required documents, not originals, to facilitate processing.
Additional Documentation	Additional documents may be requested after the initial submission, and applicants will be given time to provide these.
Eligibility Criteria	Eligibility for assistance is determined based on financial status, including income and assets, as well as residency in Maryland.
Marital Status	Applicants must disclose their marital status, which can affect eligibility and benefits.
Interpreter Services	Applicants can request interpreter services if needed, ensuring accessibility for non-English speakers.
Voter Registration	Applicants who are not registered to vote can request a voter registration form as part of the application process.

Please rate Printable Maryland Dhr Template Form

4.8

Excellent

20 Votes

Other PDF Forms

Md Resale Certificate - It is designed to be straightforward, ensuring easy compliance for businesses with legitimate resale operations.

To further ensure the protection of your proprietary information, consider utilizing resources like the WA Documents, which provide essential templates and guidance for drafting a comprehensive Non-disclosure Agreement tailored to your specific needs.

Md 510 Instructions 2023 - Form 500D emphasizes the importance of using the same taxable year or period as the federal return, ensuring consistency and simplification in tax filing practices.