Item Checklist

Checklist of Items Necessary for Medicaid Application

Upload one document for each category unless otherwise noted

Proof of Citizenship

  • Us Passport (can be expired)
  • Birth Certificate
  • Naturalization Certificate
  • Green card
  • NY Driver ID ( Not Ideal )


Proof of Social Security Number

  • Social Security Card
  • 1099 from social security


Proof of Medicare Number

  • Medicare Card (blue, green, red card)
  • Social Security Award Letter


Proof of Marital Status

  • Marriage License
  • ketubah
  • Letter from Clergy Member Starting they are married
  • Divorce decree
  • Death Certificate for spouse
  • Never Married


Proof of Income

  • Social Security Award Letter(if cannot be obtained, this should not hold up Application)
  • Proof of Pension
  • Proof of IRA Distribution
  • Proof of Holocaust Application (If Applicable)


Supplemental Health Insurance

Both are required if Applicable

  • Proof of frequencies (Bill , Letter, Multiple Bank Statements
  • Proof of Payment
  • Not Applicable
  • Copy of Card (Front or back)


Financial Bank Statements in Name & Joint

  • Current Bank Statements for all accounts
  • Prepay Card for Direct Deposit of SSA (Front & Back)

Other Assets Select all that are relevant

  • Stock/Bonds
  • Life Insurance (Cash Value)
  • Annuity(Not receiving distribution)
  • Other


Proof of Residence-Showing Complete Address

  • Utility Bill
  • Lease
  • Deed
  • Letter from Landlord/Owner of Residence
  • Rent Maintenance Bill or Receipt
  • Family Letter, also need a bill in their Name at that address


Spousal Refusal Cases only (Needed from refusing spouse)

  • Supporting Documentation to be discussed
  • Spousal Refusal Forms to be signed by refusing spouse and Applicant


Power of Attorney Form (If Applicable)

  • NYS Power of Attorney (POA)
  • Statutory Gift Rider


Signed Documents Required

  • Five Documents Requiring Applicant Signature


Irrevocable Trust with Schedule A

(Provide all relevant items)

  • Financial/Bank Statements
  • Stock Bonds
  • Life Insurance
  • Green card
  • Annuity
  • Deed
  • Other


Medicaid Card (Benefit Card) if applicable


US Veteran

Please advice, you may be eligible for additional benefits once Medicaid has been approved

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