The following is a collection of important forms for the elderly and disabled, particularly those relevant to home care and Medicaid:
Medicaid Application
Main Application
Supplement A – Required for those seeking coverage for long-term care.
Equity Statement (MAP-2050J) – For applicants that own real estate.
Income Producing Property (MAP-221) – We recommend that all applicants that own real estate complete this form – even if the property does not produce any income.
United Community Services Disability Pooled Trust
Please note: United Community Services is one of many not-for-profit agencies in NY that administers a disability pooled income trust. We have provided important forms and documents for their pooled trust which is used by many to shelter income above the Medicaid limit.
Joinder Agreement
Information and Procedures
Declaration of Trust (Master Trust)
Documenting Disability in NY State
LDSS-486T Medical Report (filled out by doctor)
LDSS-1151 Disability Questionnaire
LDSS-1151.1 Continuation Sheet (if necessary)
HIPAA – OCA Official Form No.: 960
MAP-751e Authorization to Release Medical Information – This form has been replaced by “HIPAA – OCA Official Form No.: 960”, but we have found that Medicaid will still sometimes request it. We recommend submitting both forms when requesting a disability determination.
Home Care
M11Q – This form is no longer used for most home care enrollments. However, it is still used in certain situations. Most home care enrollments do not require any forms to be filled out by the patient’s doctor.
Medicare Savings Program