Download Medicaid Planning Intake Form

Mile High Estate Planning
1610 Wynkoop Street, Suite 550, Denver, CO 80202
(T) 720-924-6171  (F) 720-399-5560  (E) [email protected]
www.MileHighEstatePlanning.com
Personal Information Form
Medicaid Applicant’s Information
Full Legal Name
Preferred Name
Date of Birth
Preferred Phone
Email Address
U.S. Citizen?
If no, please specify
Veteran? If yes, please specify branch and dates of service.
Spouse’s Information
Full Legal Name
Preferred Name
Date of Birth
Preferred Phone
Email Address
U.S. Citizen?
If no, please specify
Veteran? If yes, please specify branch and dates of service.
Couple’s Information
Home Address
Date of Marriage
Did you sign a Pre- or Post- marriage contract?
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Estate Planning Documents
Check any that you have previously completed
Husband
Wife
Will
Trust
Financial Power of Attorney
Medical Power of Attorney
HIPPA Release
Pre-paid Funeral
Arrangements
Are you the beneficiary of any
trust? (if yes, please specify)
Children
Full Name
Gender
Date of Birth
Specify
parent if not
Married shared
Does the Medicaid applicant have any minor, blind or disabled children living with them?
Medicaid Planning Information
Where does the applicant currently reside?
Has the resident recently been hospitalized or in a rehabilitation program? If yes, please describe.
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Please describe the current mental capacity of the applicant.
Is the applicant currently receiving any VA pension or service-related disability benefits?
Have any gifts of money or property been made over the past 5 years? If so please specify the
value and recipient.
Is anyone in the household currently on Medicaid?
Has anyone in the household applied for Medicaid? What is the status?
Is anyone in the household receiving Social Security?
Asset Information
Please specific the owner(s) of each asset. Include all assets currently held in trust;
the Trustee of any trust will be the owner of any trust assets.
Professional Advisors
Name
Company
Accountant
Financial Advisor
Mortgage Holder
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Real Estate
Include all real estate interests including vacation homes, time shares and undeveloped land
General Description and Address
Note any property used for business purposes
Market
Value
Loan
Balance
Owner
Furniture and Personal Effects
List major personal effects such as jewelry, collections, antiques, furs, and other valuables. For
less valuable items give a lump sum value in the last line.
Item / Description
Market Value
Miscellaneous Furniture and Household Effects
Owner
Lump sum
Automobiles
List each of your motorized vehicles, including cars, boats, and RVs
Vehicle
Type
Make, Model, Year
Market
Value
Encumbrances?
specify amount)
Owner
Intellectual Property
List trademarks, patents, registered designs, copyrights, or other intellectual property.
Type
Mile High Estate Planning
Value
Owner
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Bank Accounts
List all types of bank accounts including checking, savings, certificates of deposit, and money
market accounts. Do not include IRAs or 401(k)s here. Note: If an account is in your name for
the benefit of a minor, please provide minor’s name.
Account Type
Bank Name
Balance
Owner
Money Owed To You
List any mortgages or promissory notes payable to you or other moneys owed to you.
Name of Debtor
Date of Note
Maturity
Date
Current
Balance
Owner
Other Financial Accounts
List all stocks, bonds and investment accounts, as well as pension, profit sharing, H.R.10, IRA,
SEP, and 401(k) plans. If held in a brokerage account, lump together on one line.
Type
Financial Institution
Account No. / Plan
Name
Balance
Owner
Who are the designated beneficiaries of your retirement accounts and IRAs?
Primary
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Secondary
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Life Insurance, Annuities, Long Term Care Insurance
List any type of life insurance policy such as term, whole, group, split dollar or annuity. Please
also include any long term care insurance.
Policy
Owner
Policy
Type
Insurance Co and
Agent
Face Value
Death
Benefit
Premium
Payer
Beneficiaries
Business Interests
List any businesses such as general or limited partnerships, sole proprietorships, privately owned
corporations, professional corporations, oil interests, and farm and ranch interests.
Business Name and
Type
Business’
Market Value
Owner
Percent Owned
Do you have a
buy-sell
agreement?
Anticipated Moneys
List any expected gifts or inheritances, and any money you expect from a lawsuit.
Source of Money or
Property
When Will You
Receive It?
Specify Recipient
Value or Amount
Are you currently being sued? If yes, please attach an explanation.
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Other Assets
List any other property you have that does not fit into the above categories.
Item / Description
Value
Owner
How did you hear about Mile High Estate Planning?
___Google
___Radio Adds
___Other, Please Specify ___________________________
Thank you for taking the time to provide this information so that we are able to provide
you with the best service. Please contact MHEP if you have any questions.
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