FREDERICK COUNTY DEPARTMENT OF SOCIAL SERVICES
100 East All Saints Street
Frederick, Maryland 21701

Long-Term Care Checklist web posted May 2004


Long Term Care Checklist:

The following items are necessary to determine your eligibility for Nursing Home Medical Assistance. This information is necessary for both husband and wife, if applicable.

Items needed:

Social Security card(s)
Medicare card(s)
Health Insurance card(s)
Health Insurance Premium payment
Verification of Birth, Marriage, Death Certificate of Spouse, Divorce Decree
Life Insurance policies (confirm Face Value, Cash Value, Accumulated Dividends, Paid-up Additions)
Savings Account Passbook (with up-to-date interest or 36 months of bank statements)
Checking Account; owned or co-owned (with 36 months of statements)
Deed to Real Property owned or transferred within 36 months
Deed to Property in which Life Estate is held or has been transferred within 36 months
Property Tax Assessments
Verification of Certificates of Deposit (36 month history)
Verification of Savings Bonds (36 month history)
Verification of Stock (36 month history)
Verification of IRA or Keogh Accounts (36 month history)
Verification of Mutual Funds (36 month history)
Verification of disposal of any resource within 36 months (sold, transferred or given away)
Verification of Trust Funds (60 month history and copy of Trust)
Verification of Burial Plots
Verification of Prepaid Burial Plans or Accounts including Irrevocable Contract
Vehicles (Title or Registration)
Verification of ALL income for both Husband and Wife (gross and net income)
Power of Attorney or Guardianship papers
Verification of Annuities
Income Tax Returns for prior three years
Community Spouse's Shelter Costs

If you have any questions please contact our Agency