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Get Review Form For Medicaid 2014-2024

Date Worker Telephone BG HH Case Name South Carolina Medicaid Program Annual Review Form This form is used to review your Medicaid coverage. You must return this form to us by If you do not return this form your Medicaid will stop* This could affect the amount of your Social Security benefit. Please fill out EACH item on this form* If an item does not apply write does not apply. If an answer to any question is none or 0 write none. If you need help filling out this form call your worker listed above. Si necesita ayuda para llenar este formulario puede llamar a su trabajador cuyo nombre aparece arriba* What language do you use most English Spanish Other specify 1. Fill out the following information about the beneficiary Last Name First Name Middle Initial Mailing Address Include Apartment/Lot Number City County State Zip Code Street Address if different Include Apartment/ Lot Number Telephone Number where we can reach you including area code Phone Second Phone FOR AGENCY USE Date Received If an Authorized Representative is completing this application please complete the following Name Phone Number Address Relationship WKR003 INSTITUTIONAL HCBW Revised April 2010 Page1 2. List yourself your spouse and any dependent children* Name Social Security Number Date of Birth Marital Status Single Divorced Separated 3. Does your spouse or dependent child work Yes Married Widowed No Enter GROSS pay before taxes and deductions not take home pay. Enter zero 0 if you are not working. You must send proof of income for the past 4 weeks. Dependent Child s Income from Employment if living in the home Spouse s Income from Employment Name of person employed Employer s Name Employer s Address Employer s Phone Number including area code Gross amount earned per pay period How often paid Weekly Is anyone self-employed Every two weeks Twice a month Monthly How often paid Monthly No If yes you must send copies of all the most recently filed Personal and Business Federal income tax forms including all forms and schedules. Please name Self-Employment Business and/or Partnership Page2 4. Please list below ANY money received* You must send proof of anything listed* Other Income Amount Which family member gets this income Child Support Alimony Unemployment Benefits Veterans Benefits Workers Compensation/Long Term or Short Term Disability Cash Contributions Retirement/Pensions/Annuities How often is this income received 5. Are there any adults in the home who are not currently working If Yes tell us who and when they last worked 6. Has the applicant or spouse closed any bank accounts in the past year No If yes at what bank and in whose name s A. B. Date Closed Closing Balance Item Sold or Given Away Person to Whom it was Sold or Given Amount Received Page3 8. Does anyone have any assets or resources like those listed below No You must send proof of the value of each. Company name address and phone Account/Policy What is the Asset/Resource Yes No Who does it belong to number and/or Description value Cash on Hand Checking Account s Savings Account s Certificate s of Deposit Annuities/Trusts/Stocks/ Bonds Home Property location/description Other Property Life/Burial insurance How much is owed Burial Contracts Burial Plots Vehicles make model year Retirement Account Other please be specific 9.

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