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Client Screening
For ohio purpose
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For whom are you considering applying for Medicaid?
*
Yourself
Your Parent
Your Spouse
Your Client
Other
Is the individual applying for Medicaid married or single?
*
Single
Married
Where does the individual applying for Medicaid currently reside?
*
At home
In a friend or family member's home
In assisted living
In rehab. care temporarily
In a nursing home permanently
What is the age of the individual applying for Medicaid?
*
Under 65 and not disabled
Under 65 and disabled & receiving SSDI
65 - 85
Over 85
In a nursing home permanently
For what reason is the individual applying for Medicaid?
*
For home care
For assisted living care
For nursing home care
Does not require long term care
What is the total monthly income of the individual applying or couple (if both spouses are applying) applying for Medicaid?
*
Less than $1,250 / month
Between $1,250 - $1,750 / month
Between $1,750 - $2,850 / month
Between $2,850 - $5,700 / month
Over $5,700 / month
Does the individual applying for Medicaid have a life insurance policy and if so what is the face value of the policy?
*
No life insurance
Life insurance with a Cash Surrender Value (CSV) less than $1,500
Life insurance with a CSV between $1,500 - $10,000
Life insurance with a CSV over $10,000
Life insurance with an unknown CSV
Does the individual applying for Medicaid own a home and if so, what is the value of their home minus any outstanding mortgage?
*
No, they do not own a home
Yes, they own a home and their equity is less than $200,000
Yes, they own a home and their equity is between $200,000 - $713,000
Yes, they own a home and their equity is between $713,000 - $750,000
Yes, they own a home and their equity is between $750,000 - $1,071,000
Yes, they own a home and their equity is over $1,071,000
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 - $5,000
Between $5,000 - $10,000
Between $10,000 - $20,000
Between $20,000 - $35,000
Between $35,000 - $50,000
Between $50,000 - $150,000
Over $150,000
Does the applicant intend to reside in Ohio?
Yes
No
The County in which the Medicaid applicant lives
*
Select
Butler
Clermont
Darke
Hamilton
Montgomery
Preble
Warren
individual County reside
What benefits and / or coverage does the individual applying for Medicaid currently have? Check all that apply.
*
Medicare / Medicare Advantage Plan
Long Term Care Medicaid
Regular (ABD) Medicaid
Veterans Pension
Social Security Disability
None of the above
How soon do you anticipate the need for Medicaid?
Immediately
Within 3 Months
Over 3 Months
Your First Name
*
Your Last Name
*
Email Address
*
Phone
Best time to call?
Morning
Afternoon
Anytime
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