Prescription Drug Coverage
Is the applicant a Veteran?
Do you receive any VA benefits?
BILLS TO BE MAILED TO
Check applicable boxes, provide copies of applicable paperwork upon admission.
Reason applicant needs skilled care:
Do you have a Substance Use Disorder(Alcohol/drugs)
(mark all that apply)
Has applicant previously voted in North Dakota?
Does applicant wish to vote?
You must complete the following UNLESS applicant is full VA Contract or has been Approved for Medicad. If skipping, scroll to the end of application for signature.
1. List all the transfers or gifts of assets with the past five years by you and your spouse, including transfers of a remainder interest in real property.
2. List all pre-paid burial contracts, burial accounts, and pre-paid burial or funeral items owned by you or your spouse or by a third party for the benefit of you or your spouse.
3. List all sources of income for you and your spouse, including but not limited to rental payments, CRP income, long-term care insurance benefits, Social Security benefits, veteran’s benefits, and employment income.
4. Except for personal effects, list all assets owned by you and your spouse, including the cash surrender value of life insurance, stocks, bonds, vehicles, life estates, and pensions, with the value as of the date of admission into the nursing home. (Attach additional pages if needed.)
Do you or your spouse have any pending legal action from which you may receive money, including an inheritance or a settlement?
Are you or your spouse employed by another?
Are you or your spouse self-employed?
Are you or your spouse actively engaged in farming?
Do you or your spouse have an ownership interest in a business?
List all Debts Owed by You or your Spouse:
This questionnaire complies with section 50-10.2-05 of the North Dakota Century Code. By my signature below, I hereby authorize the nursing home to contact the county and/or state social services office for information regarding my Medicaid application and eligibility, and I hereby release and authorize the county and/or state social services office to release any information to the nursing home. I also authorize the nursing home to contact any and all of the above-identified financial institutions to obtain information regarding my assets and income, and I hereby release and authorize the financial institutions to release any information to the nursing home. I further authorize the nursing home to release to its attorneys any information regarding my application for admission. I understand that providing false information could result in discharge and/or denial of my application. The answers provided herein are true and correct to the best of my knowledge and information.