Medical Insurance If Yes, confirm the details on Are you currently covered by medical insurance? the application or request the → company and policy number. No 1233 Requested Verification of Yes – coverage and premium Details: Allocation If the allocation question is blank or No and the person is going into a nursing home: you like to allocate, or give, part of your income to your: → Spouse, Child, or Other dependent relative who was living with the applicant prior to admission? No Change Allocation Change Other Financial Accounts 1233 Verification Requested – Does anyone have any financial accounts for you or is holding → for you that has not been listed? Have you added any names to any accounts? No Yes Details: 1233 Verification Requested Closed Financial Accounts – In the past five years have you or your spouse closed or transferred → any type of financial account such as bank, investment, or retirement accounts? No Yes Details: Real Property 1233 Verification Requested – In the past five years have you or your spouse sold or given away → your home or any other property? This includes transferring your home into a life estate. No Yes If a transfer is indicated: When did you transfer the property and in what county and state did → the transfer take place? Or Where have you lived in the past five years? → Details:
Medical Insurance → Are you currently covered by medical insurance? If Yes, confirm the details on the application or request the company and policy number. 1233 – Requested Verification of coverage and premium No Yes Details: Allocation If the allocation question is blank or No and the person is going into a nursing home: → you like to allocate, or give, part of your income to your: Spouse, Child, or Other dependent relative who was living with the applicant prior to admission? No Change Allocation Change Other Financial Accounts → Does anyone have any financial accounts for you or is holding for you that has not been listed? Have you added any names to any accounts? 1233 – Verification Requested No Yes Details: Closed Financial Accounts → In the past five years have you or your spouse closed or transferred any type of financial account such as bank, investment, or retirement accounts? 1233 – Verification Requested No Yes Details: Real Property → In the past five years have you or your spouse sold or given away your home or any other property? This includes transferring your home into a life estate. No Yes If a transfer is indicated: → When did you transfer the property and in what county and state did the transfer take place? Or → Where have you lived in the past five years? 1233 – Verification Requested Details: