Representative

If you are filling out this form on behalf of the Client, tell us about yourself. If you are the Client, skip this section.

Case Type

A few questions about who the Client is. This drives which sections appear below.

Client Demographics

The Client is the person who needs long-term care (the institutionalized spouse, if married).

Health & Capacity

Helps us understand the Client's capacity to sign documents and which planning strategies are still available.

People Providing Care

Family members or other people currently providing custodial or other types of care.

Income (Monthly)

Add a line for each income source. Gross is preferred; if you only know the net deposit, leave gross blank and we'll estimate. Include both spouses' income.

For a retirement account required minimum distribution (RMD), provide the most recent annual RMD and divide by 12. If you don't know the annual RMD but you see a monthly amount being deposited into the Client's bank account, provide the amount of the monthly deposit and tell us that info in the Description.

Assets

Carefully list each asset owned by the Client and the spouse, if there is a spouse. Medicaid counts all the assets, no matter whether those assets are community property or separate property. Prenuptial agreements and marital property agreements do not protect assets from Medicaid. Check a couple of months of activity in the Client's checking account for any regular deductions. You may discover premiums being paid on a life insurance policy you did not know about. Life insurance policies are often problematic when applying for Medicaid.

Gifts & Transfers — 5-Year Lookback

List any gifts you gave, transfers for which you received less than the value of the item you conveyed, or trust funding within the last 60 months. If you regularly pay a bill for a friend or family member, include that. These can trigger a Medicaid penalty period.

Monthly Expenses

Beneficiaries and Relevant Family Members

To whom does the Client plan to leave their assets after they die? If the Client is married, to whom does the spouse plan to leave their assets?

Exempt Resources

If you own these special assets, Medicaid does not consider them when evaluating your eligibility for long-term care benefits.

Existing Estate Planning Documents

Expected Monthly Cost of Care

If currently receiving long-term care, use the actual amount being paid. If planning ahead, leave blank and we'll default to the San Antonio private-room average ($6,935 / mo).

Liabilities

Goals