Medicaid Online Questionnaire Main

Please answer the following questions, to get the application process started.

If you are unsure about the value (or even existence) of an asset or income, simply enter “TBD” (to be determined) for now.

After completing this questionnaire, please submit the supporting documents for each of your (and your spouse’s) income and asset. Note: even if an income is reflected on your bank statement, we still need the actual income statement. For example, even if you receive your pension or social security benefits via direct deposit, we still need the actual pension or social security statement.

You may submit your supporting documents via the Secure Client Portal, via email at Abraham@Mazloumi.com, or via fax at 516-283-0250.

Applicant's Full Name

Applicant's First Name

Applicant's Last Name

Caretaker's First Name

Person "In charge of Applicant"

Caretaker's Last Name

Caretaker's Relationship to Applicant

Caretaker's Primary Phone Number

1 - Applicant Date of Birth

2 - Applicant City, State and Country of Birth

3 - Applicant Marital Status

4 - Full Maiden Name (birth name before marriage)

Enter "N/A" if not applicable

5 - Applicant Soc Sec #

6 - Applicant Current Address

7 - Applicant Primary Phone Number

8 - Does Applicant have MediCARE?

9 - Applicant's Supplemental Health Insurance Company

Medigap (Medicare Suppl.) Policies, such as UnitedHealthcare, etc.

10 - Monthly Premium for Supp Health Ins

Enter -0- if none or TBD if unknown (other than Medicare)

11 - Medicare Part D Prescription Drug Plan

List name of Insurance Co. Enter N/A if no Part D Plan

12 - Monthly Premium for Prescription Drug Plan

Enter -0- if none or TBD if unknown

13 - Physician (for Disability Determination)

Name & Contact Info of Primary ("Main") Physician

14 - Salaries, Wages, Commissions

Total combined, if more than one. Enter "0" if none

15 - Self-Employment Income

Total combined, if more than one. Enter "0" if none

16 - Pension Income

Total combined, if more than one. Enter "0" if none

17 - IRA Required Minimum Distributions

Per Month. Enter "0" if none

18 - Annuity Income/Distributions (per month)

Total combined, if more than one account. Enter "0" if none

19 - Dividends and/or Interest (total, per month)

Total combined, if more than one. Enter "0" if none

20 - Social Security Pension Income

Per Month. Enter "0" if none

21 - Social Security Supplemental Income

Per Month. Enter "0" if none

22 - Social Security Disability Income

Per Month. Enter "0" if none

23 - Rental Income

Total per month. Enter "0" if none.

24 - Checking Account Balance

Total combined, if more than one account. Enter "0" if no account

Number of Checking Accounts

Select the number of accounts

25 - Savings Account Balance

Total combined, if more than one account. Enter "0" if no account

Number of Savings Accounts

Select the number of accounts

26 - IRA Current Balance

Total combined, if more than one account. Enter "0" if no account

Number of IRA Accounts

Select the number of accounts

27 - IRA-Roth Current Balance

Total combined, if more than one account. Enter "0" if no account

Number of IRA-Roth Accounts

Select the number of accounts

28 - CD(s) Current Balance

Total combined, if more than one account. Enter "0" if no account

Number of CDs

Select the number of accounts

29 - Annuity Current Balance

Total combined, if more than one annuity. Enter "0" if no annuity

Number of Annuities

Select the number of annuities

30 - 401k Current Balance

Total combined, if more than one account. Enter "0" if no account

Number of 401k Accounts

Select the number of accounts

31 - Brokerage Account Current Balance

Total combined, if more than one account. Enter "0" if no account

Number of Brokerage Accounts

Select the number of accounts

32 - Bonds Current Balance

Total combined, if more than one account. Enter "0" if no account

33 - Stocks Current Balance

Total combined, if more than one. Enter "0" if none

34 - Trust Asset(s)'s Value

Total combined asset(s) owned by Trust created by or for you. Enter "0" if none

Number of Assets titled to Trust

Select the number of assets owned by Trust

35 - Trust Income (payable to applicant or spouse)

Total monthly trust income. Enter "0" if none

36 - Rent to Landlord (monthly)

Enter "0" if Applicant doesn't pay rent

37 - Primary Residence, Net Equity Value

Value of your home, less mortgage. Enter "0" if none

38 - Real Estate Investment, Net Equity Value

Value of Real Estate Investm/Vacation Home, excl. Primary Residence

39 - Mortgage Payment (monthly)

Enter "0" if none

40 - Property Taxes (monthly)

Enter "0" if Applicant doesn't own real estate

41 - Water Payment (monthly)

Enter "0" if none

42 - Life Insurance CASH Value(s)

Total combined, if more than one policy. Enter "0" if no policy

Number Life Insurance Policies

Select the number of policies

43 - Car: Owner & Year/Make/Model & Value

Enter "N/A" if not applicable.

44 - Value of Business, Partnerships, LLCs, etc.

Total combined value, if more than one. Enter "0" if none

Total Number of Businesses, Partnerships, LLCs, etc.

State in how many companies / businesses you own an interest

45 - Prior Gifts/Transfers for less than FMV

Only for Nursing Home Medicaid App. Prior Gifts/Transf. in last 60 months (2K+). Enter "0" if none.

46 - Select all estate documents you already have

To multi-select: (PC) hold down Control key, (Mac) hold down Shift key

47 - Do you want to protect your home against potential liens or estate recovery by NYS, etc.?

Please state here any other issues & concerns you would like us to discuss or be aware of

If you have a SPOUSE: click here to continue Hide

Spouse Full Name

Spouse First name

Spouse Last Name

Spouse Primary Phone Number

48 - Spouse Date of Birth

49 - Spouse's City, State and Country of Birth

50 - Spouse Full Maiden Name (birth name before marriage)

51 - Spouse's Soc Sec #

52 - Spouse Current Address

53 - Does Spouse have MediCARE

54 - Spouse Supplemental Insurance

Medigap (Medicare Suppl.) Policies, such as UnitedHealthcare, etc.

55 - Spouse Monthly Premium for Supp Health Ins

Enter -0- if none or TBD if unknown (other than Medicare)

56 - Spouse Medicare Part D Prescription Drug Plan

List name of Insurance Co & monthly premium. Enter N/A if no Part D Plan

57 - Monthly Premium for Prescription Drug Plan

Enter -0- if none or TBD if unknown

58 - Spouse's Physician (for Disability Determination)

Name & Contact Info of Primary ("Main") Physician

59 - Spouse Salaries, Wages, Commissions

Total combined, if more than one. Enter "0" if none

60 - Spouse Self-Employment Income

Total combined, if more than one. Enter "0" if none

61 - Spouse Pension Income

Total combined, if more than one. Enter "0" if none

62 - Spouse IRA Required Minimum Distributions

Per Month. Enter "0" if none

63 - Spouse Annuity Income/Distributions (per month)

Total combined, if more than one account. Enter "0" if none

64 - Spouse Dividends and/or Interest (total, per month)

Total combined, if more than one. Enter "0" if none

65 - Spouse Social Security Pension Income

Per Month. Enter "0" if none

66 - Spouse Social Security Supplemental Income

Per Month. Enter "0" if none

67 - Spouse Social Security Disability Income

Per Month. Enter "0" if none

68 - Spouse Rental Income

Total per month. Enter "0" if none

69 - Spouse Checking Account Balance

Total combined, if more than one account. Enter "0" if no account

Number of Checking Accounts

Select the number of accounts

70 - Spouse Savings Account Balance

Total combined, if more than one account. Enter "0" if no account

Number of Savings Accounts

Select the number of accounts

71 - Spouse IRA Current Balance

Total combined, if more than one account. Enter "0" if no account

Number of IRA Accounts

Select the number of accounts

72 - Spouse IRA-Roth Current Balance

Total combined, if more than one account. Enter "0" if no account

Number of IRA-Roth Accounts

Select the number of accounts

73 - Spouse CD(s) Current Balance

Total combined, if more than one account. Enter "0" if no account

Number of CDs

Select the number of CDs

74 - Spouse Annuity Current Balance

Total combined, if more than one annuity. Enter "0" if no annuities

Number of Annuities

Select the number of annuities

75 - Spouse 401k Current Balance

Total combined, if more than one account. Enter "0" if no account

Number of 401k Accounts

Select the number of accounts

76 - Spouse Brokerage Account Current Balance

Total combined, if more than one account. Enter "0" if no account

Number of Brokerage Accounts

Select the number of accounts

77 - Spouse Bonds Current Balance

Total combined, if more than one account. Enter "0" if no account

78 - Spouse Stocks Current Balance

Total combined, if more than one. Enter "0" if none

79 - Spouse Trust Asset(s)'s Value

Total combined assets owned by Trust created by or for you. Enter "0" if none

Number of Assets titled to Trust

Select the number of assets owned by Trust

80 - Spouse Trust Income (payable to applicant or spouse)

Total monthly trust income. Enter "0" if none

81 - Spouse Rent to Landlord (monthly)

Enter "0" if spouse does not pay rent

82 - Spouse Primary Residence, Net Equity Value

Value of your home, less mortgage. Enter "0" if none

83 - Spouse Real Estate Investment, Net Equity Value

Value of Real Estate Investm/Vacation Home, excl. Primary Residence

84 - Spouse Mortgage Payment (monthly)

Enter "0" if none

85 - Spouse Property Taxes (monthly)

Enter "0" if spouse doesn't own real estate

86 - Spouse Water Payment (monthly)

Enter "0" if none

87 - Spouse Life Insurance CASH Value(s)

Total combined, if more than one policy. Enter "0" if no policies

Number Life Insurance Policies

Select the number of policies

88 - Spouse Car: Owner & Yr/Make/Model & Value

Enter "N/A" if not applicable.

89 - Spouse Value of Businesses, Partnerships, LLCs, etc.

Total combined, if more than one. Enter "0" if none

Total Number of Businesses, Partnerships, LLCs

State in how many companies / businesses you own an interest

90 - Spouse: Prior Gifts/Transfers for less than FMV

Only for Nursing Home Medicaid App. Prior Gifts/Transf. in last 60 months (2K+). Enter "0" if none

91 - Spouse: Select all estate documents you already have

To multi-select: (PC) hold down Control key, (Mac) hold down Shift key

92 - Do you want to protect your home against potential liens or estate recovery by NYS, etc.?

Few areas of the law are as complex and potentially frustrating as Medicaid planning and applications. The complex regulations and requirements of New York Medicaid are constantly evolving, making the risk of failure quite real. A small mistake can result in a denial of coverage, and significant financial losses. The legal team at Abraham Mazloumi & Associates has detailed expertise in New York State Medicaid law, guiding clients through the Medicaid application process and ensuring eligibility is obtained at a success rate that is unrivaled.

Our attorneys are experts in the Medicaid guidelines and their implications, and can identify the specific approach that your case requires so that your application is prepared and filed properly, and ensuring you a secure financial future. We represent you before the local Medicaid agency and we communicate directly with Medicaid workers on both the County and State levels enabling us to deal with issues in the most efficient manner possible. Our relationships allow us to have the Medicaid applications expedited and given the proper attention by the County worker assigned to each case.

Our staff makes themselves readily available to our clients if any questions may arise at any point during the application process. We establish working relationships with the clients and their families through every step of the process implementing the advice given from start to finish. With our help, you can approach the Medicaid application process confidently, knowing that you have the best available information, preparation and support from our team.

Contact us today to begin the conversation.

To speak with an attorney, please call Mazloumi Law at 516-466-7526 or email us at info@mazloumi.com to set up a consultation at your convenience.

Medicaid Online Questionnaire Main

(516) 466-7526