SC Medicaid Instructions

1. This Medicaid form is for adults who are 65 or older or for individuals with disabilities who need help to pay for one of the following:
   • Long Term Care Services that help them stay in their home.
   • Nursing Home Care
   • Hospital Stays of 30 days or more.

   For more information about Medicaid, go to FAQ (Frequently Asked Questions).

   View Terms and Definitions used in this application.

2. The person applying for Medicaid may fill out this form. If that person needs help, a trusted person, such as a parent, spouse, or adult child, may fill out the form for the person applying for Medicaid.
   
   
3. BEFORE YOU BEGIN: To complete this form you will need information about the person applying for Medicaid and his/her spouse (husband or wife) and his/her children under 21 who live in the home. Gather the following information if it applies to any of these people.
   • Social security numbers
   • Railroad retirement numbers
   • Medicare numbers
   • Veterans benefit numbers
   • Bank statements for all bank accounts, CD's (certificates of deposit), mutual funds, etc. This includes a current bank statement. If applying for nursing home care, we will need as many statements as you can obtain for the past 36 months.
   • All health insurance policies (health, hospital, cancer and life insurance)
   • Contracts for prepaid burial expenses
   • Tax receipts for any cars or property owned
   • Property deeds
   • Copies of any trust agreements
   • Mortgage statements
   • Other financial information

   If you are already eligible for Medicaid and applying for nursing home care, a review of your assets must be made. You will need to provide information about any property that has been in your name or your spouse's name or both of your names during the past 36 months. This includes closed bank accounts as well as current accounts and deeds to property that may have been sold or transferred.

4. The more information you can give, the easier it will be for your form to be processed. If you do not have all of the information asked for to complete the form, you may still send this form to Medicaid.
   
   

   It must be signed by the person applying for Medicaid to count as an application. Please read the Medicaid Recovery Estate Brochure before you sign the application.

   
   
5. Once the form is received, someone from Medicaid will contact you to get any missing information. Be sure your name, address and telephone numbers are correct.

Next: Form Instructions