* = Required Information
Name of Person Completing This Form
*
Full Legal Name
*
Date of Birth
Social Security #
Anticipated Admission Date
Admit Location
Financial Case #
MA/PMI #
Medicare Part A #
Part A Effective Date
Medicare Part B #
Part B Effective Date
Medicare Part D Prescription Drug Plan
City & State of Birth
Marital Status
PARENT INFORMATION
(for current or future RSDI application)
Mother
Maiden Name
Address
Phone #
Social Security #
Mother's Place of Birth
Notes
Father
Address
Phone #
Social Security #
Father's Place of Birth
Notes
Guardianship Status
Self
State
Private
Conservator
Relation
Phone # and/or Email address of contact
Guardianship Fee Paid
Yes
No
What is the fee?
*If Guardian, please provide a copy of court documents for the file
Military Experience
Yes
No
Probation
Yes
No
Hospitalizations in Past Year
Yes
No
Date admitted & duration of stay
Incarcerations in Past Year
Yes
No
Date admitted & duration of stay
COUNTY/FINANCIAL INFORMATION
Case Manager
Address
Phone #
Financial Worker
Address
Phone #
County of Financial Responsibility
Host County
Waiver Type
CADI
DD
TBI
None
Explain other billing arrangements
Banking Institution Name & Address
Checking Account #
Savings Account #
Life Insurance
Burial Account Name and Address
Trust Fund
Yes
No
It is irrevocable?
Yes
No
Name and Phone number of trustee
Savings Bonds
Yes
No
Name on bond(s)
Name of person with possession of the bond(s)
EMPLOYMENT
Were you working prior to moving to A Helping Hand Senior Care Services?
Yes
No
Are you continuing with that employer after admission to A Helping Hand Senior Care Services?
Yes
No
Average Monthly Gross Earned Income
Name of Employer
Address
Phone #
Which of the following unearned income funding sources are you receiving? Check all that apply.
GRH (Group Residential Housing)
Amount
SSI (Supplemental Security Income)
Amount
RSDI (Retirement, Survivors, Disability Insurance)
Amount
MSA (Minnesota Supplemental Aid)
Amount
GA (General Assistance)
Amount
SNAP (Food Support)
Amount
SMLB/QMB (Medicare Buy-in)
Amount
If you are receiving Social Security benefits (SSI or RSDI) please list your current representative payee
Name of Payee
Address
Phone #
Would you like A Helping Hand Senior Care Services LLC. to become your representative payee (there is no fee for this service)
Yes
No
Paying Child Support
Yes
No
Do you pay a spend down to a provider
Yes
No
Provider Name
Phone #
Amount of monthly spend down
Do you qualify for any of the following income disregards:
MA-EPD (Medical Assistance-Employed Persons of Disability)
DAC (Disabled Adult Child)
1619B Status
Signature (of person completing this form)
*
Date
*
Submit