Health care


Form List of Documents Required for Medicaid Application


The following documents are required for the applicant and spouse and any minor children under the age of 21.

A.   Proof of identity and family relationships

  • Social Security Card
  • Birth or Baptismal Certificates
  • Military Discharge Papers
  • Marriage Certificate
  • Death Certificate of Spouse

For those family members not born in the U.S.A. 

  • Certificate of Naturalization
  • Passport and/or Visa
  • Alien registration cared

 B.  Residency and Living arrangement

  • Rent receipt and/or lease
  • Utility bills (most current)
  • Mortgage statement, property and school tax bills (most current)
  • Two letters of residence, from other than relative, stating length of time at given address
  • Letter from person you live with verifying that they supply room and board

      C.  Income

    • Pay stubs for previous eight weeks
    • Unemployment insurance book
    • Statement of rental and/or room and board  income          
    • Support payments divorce or separation papers
    • Award letter and/or photocopy of check for the following benefits:

                a.  Social Security
                b.  Veterans
                c.  Union pension
                d.  Railroad retirement
                e.  Insurance endowments
                f.   N.Y.S. disability
                g.  Workers Compensation

      • If self-employed; business book and records
      • Tax returns for the past two years

            D.  Resources

          • Bank books (including IRA, CD and money market accounts) for past 60 months including closed accounts with copy of title page
          • Checking account each statement for the past 60 months (with copies of checks over $2000) statements
          • Title page of Life insurance policies and a letter from carrier stating the current cash value
          • Stocks and Bonds Certificates.  If in a brokerage account, each statement for the past 60 months
          • Real Estate Deeds
          • Health and Accident insurance policies and latest premiums
          • Medicare card
          • Closing papers on property sale
          • Deed to Burial Plot

              E.  Medical Forms IF APPLYING FOR HOMECARE

            • DSS 486 'Physician's Statement for Determination of Disability' (if under 65 in Nassau County)
            • DMSB1 Long Placement Form (for Home Care in Nassau County)
            • 517 Physician's Request for Home Health Aide (for Home Care in Nassau County)
            • M11Q Request for Home Care (Home Care for New York City)

                F.  Other

              • Spousal Refusal, if applicable
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