Client Screening

Thank you for your interest. Please note that our services are currently
only available to Ohio residents.

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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

For what reason is the individual applying for Medicaid? *

• In home care
• Assisted living
• Skilled nursing facility
• Does not require long term care services

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 cash 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 *SelectButlerClermontDarkeHamiltonMontgomeryPrebleWarren

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

County their the

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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