Can I Qualify?

Confidentiality Statement: This information will be kept confidential and in no way will be disclosed to any other party.

You don't necessarily need to complete this entire form - if all you care to submit is your name and contact information (in RED), that's fine with us. We will respond promptly!


Please Select One:
My family member is currently in a nursing home.
My family member may be entering a nursing home within the next few months.
I am preplanning for a family member.
Not sure.

Contact Information:

  Your Name
  Your full address
(street, city, state, zip)
  Your Phone
  Your Email
  Best time to call
(We respond to immediate needs within one business day.)

Potential Medicaid Applicant Information:

  Name of family member who needs nursing home care in Florida
  Is this person single or married or single Single Married
  Area that best describes where the Florida Resident lives

Brief Questionnaire:

Complete the questionnaire for the family member applying for Medicaid:

  Monthly Income from all sources:
Medicaid
Applicant:
Spouse
(if applicable):
  Social Security
  Retirement / Pensions
  Annuity Income
  Other Income
(e.g. IRA, VA, Long-Term-Care Benefits, etc...)
  Has the applicant gifted any assets in the last 3 years, if yes fill out the comment section with details:
Yes No
  Applicant's / Spouse's Assets:
Amount
(in whole dollars)
  CDs
  Mutual Funds / Stocks
  Bonds
  IRAs
  Money Market / Savings
  Checking
  Other
(e.g. Credit Union, Trust Account, Cash Value Insurance, etc...)
  Does the applicant / spouse own a home, if so estimated value
  Any life insurance policies with cash value

  Do you or another family member have Power of Attorney (POA) for the applicant: Yes No
 
Disclaimer: Medicaid Information Resource (MIR) does not practice law. MIR has relationships with properly licensed FL attorneys. Should it become necessary for any legal documents to be prepared or modified this is done solely by attorneys properly licensed in the state of Florida.

How long will
your money last
after you enter
a nursing home?

Contact: Bill Ruffing, Medicaid Information Resource
2629 McCormick Dr, Suite 101, Clearwater, FL 33759
Toll Free: 866-755-0620 | Tampa Area: 727-735-0620
Email: Support@MedicaidResource.com
Call or email for your free copy of the Florida Medicaid Guide!