Item Checklist
Checklist of Items Necessary for Medicaid Application
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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