Medicaid Application Checklist

1. Birth certificate, marriage license and citizenship/naturalization papers

2. Social Security Card

3. Medicare Card

4. Health insurance card (example, Blue Cross)

5. Life insurance policy(ies)

6. Burial plot information

7. Irrevocable Funeral Agreement or any agreement with a funeral director, Burial Trust or Burial Space information

8. Most recent payment stub for health insurance. If health insurance is a part of a pension benefit, let us know the name of the company responsible for the premium

9. Copy of bank statements for all accounts for last six months

10. Information regarding other assets, including stocks, bonds, Certificates of Deposit, Money Market, IRA’s, property other than your home, etc.

11. Proof of Social Security benefits, Pensions, VA Benefits or other income. Pursuant to Family Independence Agency policy, bank statements are not proof of current income. Acceptable verifications include check stubs, award letters, or statements from the responsible agency. Verification must be for the current year, not from previous years.

12. Shelter costs (i.e. rent receipts, utility bills, real estate taxes and home insurance)

13. Other information:

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