1. Medicaid Application Information List
Please provide the following information to our office as soon as possible.
Please call if you have any questions.
Client Name:______________________ County______________ Date of Qualification:___________
Needed Provided
  Identification
  Social Security Cards for all applicants
  Certificate of Naturalization or Alien Registration Card
  Power of Attorney
  Birth Certificate for applicant
  Death Certificate for deceased spouse (or parent, if applicant is under 21)
  Marriage Certificates
  Hospital and Medical Insurance ID cards, with proof of cost to you
  Medicare cards
  Nursing Home Bill
  Prepaid Burial, Mausoleum etc.
  Motor Vehicle Registration
  Life Insurance Policies (Statements reflecting cash / death / face values)
  Bank books, Checking Account Statement, CD’s, All accounts for the past 36 months
  Proof of IRA Accounts, Savings Certificates, or other forms of saving or investments
  Stocks, Bonds, Credit Union Statements, or proof of any other resource
  Proof of Trust Accounts
  Award Letter or other proof of current Pension, Social Security, Veterans or Retirement Income
  Real Estate information if residence is owned (deed, tax bills, mortgage principal, mortgage interest, escrow
account analysis, water/sewer bill, homeowner’s insurance etc.), and for all properties
  Records of Income and Expenses in connection with property owned by you
  Rent receipts
  Statement of Living Arrangements
  Military Service Information
  Divorce / Annulment / Separation papers
  Court Ordered Support payments and/or Proof of Child Support or Alimony actually received