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Free Planning Guide for Caregivers | Contact Us

For whom are you considering applying for Medicaid? *

Yourself
Your spouse
Your parent
Other loved one

Where does the individual applying for Medicaid currently reside? *

At home
In the home of a friend or family member
In an assisted living community
In rehab. care following a hospital stay
In a long term care nursing home

What is the age of the individual applying for Medicaid? *

Under 62
62 - 65
65 - 85
Over 85

For what reason is the individual applying for Medicaid? *

For nursing home care
For assisted living care
For home care
None of these reasons

Is the individual applying for Medicaid married or single? *

Single
Married

Is the individual a veteran or the widow / widower of a veteran? If so did they serve during war-time? *

Veteran (spouse, widow or widower of a veteran)
Wartime Veteran (spouse, widow or widower of a war-time veteran)
Not a veteran

What is the total monthly household income of the individual or couple applying for Medicaid? *

Less than $1,200 / month
Between $1,200 - $2,400 / month
Over $2,400 / month

Does the individual applying for Medicaid own a home and if so what is the value of their home equity? *

No, they do not own a home
Yes, they own a home and their equity is less than $100,000
Yes, they own a home and their equity is between $100,000 - $250,000
Yes, they own a home and their equity is between $250,000 - $500,000
Yes, they own a home and their equity is over $500,000

What are the total financial assets of the individual or couple applying for Medicaid (not including their home)? *

Less than $2,000
Between $2,000 - $25,000
Between $25,000 - $60,000
Between $60,000 - $115,000
Over $115,000

How soon do you anticipate the need for Medicaid?

Immediately
Within 3 months
Over 3 months

What benefits and / or coverage does the individual applying for Medicaid currently have? Check all that apply.

Medicare
Social Security Disability
Veteran's Pension
Life Insurance
Burial Insurance
Medicaid

First Name *

Last Name *

Email Address

Phone *

Best time to call?



  • Morning
  • Afternoon
  • Evening
  • Anytime

Applicants Home Address

City

State

Zip Code

Spam Verification: What is 7 + 3? *