Claimant Name (person to receive benefit) :
Veteran's Name :
Phone - Home:
Main Contact Name (Nearest Relative) :
Main Contact Phone Work:
Home:
Cell:
Main Contact Address - Street:
State:
Main Contact Email:
How did you hear about us?:
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Addus HealthCare
Aegis Living
Atria Senior Living
Brookdale Senior Living
Century Park Associates
Emeritus Senior Living
Hawthorn Retirement Group
Holiday Retirement Group
Sunrise Senior Living
Internet
Other
Referral Address (If known) - Street:
Referral Email (If known):
Claimant is applying as :
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Veteran with a dependent
Veteran
Spouse of a deceased veteran
If you are a surviving spouse, have you re-married since the death of the veteran?
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Yes
No
Receiving Medicaid? :
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Yes
No
Have you applied for Medicaid? :
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Yes
No
Current living situation:
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Assisted Living
Home
Home/Child
Independent Living
Group Home
Memory Care Community
Other
Caregiver Paid? :
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Yes
No
Veteran Military Qualifications: Date of Entry:
Veteran Date of Separation
Did veteran serve at least 90 days of active duty?
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Yes
No
Veteran Honorable Discharge?
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Yes
No
Claimant Age 65 or older?
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Yes
No
Do you have an original or certified copy of the veteran's Discharge Papers or DD214's or sometimes called Separation Papers? Yes
please click here for instructions on how to request them .
Disabled?
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Yes
No
Receiving VA disability benefits?
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Yes
No
Monthly benefits received:
Excluding personal home, car and personal possessions, are your liquid assets in excess of $50,000?:
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Yes
No
Veteran monthly income to include Social Security, Pensions, Annuities, IRA distributions, LTC insurance, interest/dividends and/or any other monthly income: $
Spouse (living) monthly income to include Social Security, Pensions, Annuities, IRA distributions, LTC insurance, interest/dividends and/or any other monthly income: $
Gross monthly unreimbursed medical expenses (out of pocket) to include: Provider expenses, Medicare supplements, LTC premium, incontinence products, insulin, oxygen and/or any other regularly occurring out of pocket expenses:
$
Additional
Comments:
