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Documents used along the form

The Michigan DHS 4574 form is essential for individuals applying for health care coverage while residing in a nursing facility. Alongside this form, several other documents may be required to complete the application process effectively. Below is a list of these documents, each serving a specific purpose in the application for health care coverage.

  • DCH-1426, Application for Health Coverage and Help Paying Costs: This form is used when other family members wish to receive assistance with medical expenses. It helps to determine eligibility for health coverage beyond the individual applying for nursing facility care.
  • Lease Agreement: For those renting property in Georgia, understanding the terms and conditions is vital, and the Forms Georgia provides a valuable resource for the necessary documentation.
  • DHS-4574-B, Assets Declaration Patient and Spouse: This document collects information about the assets owned by the patient and their spouse. It is crucial for assessing eligibility for health care coverage and determining which assets can be protected for the spouse.
  • Proof of Income Documentation: Applicants must provide evidence of their income, which may include pay stubs, tax returns, or Social Security statements. This information is vital for evaluating the financial eligibility for health care coverage.
  • Identification Documents: A valid form of identification, such as a driver's license or state ID, is required to verify the applicant's identity. This step ensures that the application process is secure and accurate.

Gathering these documents in advance can streamline the application process and increase the chances of a timely approval. Be sure to review each document carefully to ensure all information is accurate and complete.

Michigan Dhs 4574 Preview

APPLICATION FOR HEALTH CARE COVERAGE

PATIENT OF NURSING FACILITY

Michigan Department of Health and Human Services

HELP IS AVAILABLE

FOR OFFICE USE ONLY

Beneiciary Name

Client ID

Case Number

County

District

Section

Unit

Specialist

 

 

 

 

 

The Michigan Department of Health and Human Services must help all persons ill out the application, when requested. If you need help, please call or visit your specialist or the ofice named below. If you need an interpreter, the Department will provide one free of charge or you may use one of your choice. If you are refused help in illing out the application, call 855-275-6424 or 855-789-5610.

Do you need the Department to provide an interpreter to help you at the interview? c Yes

c No

If yes, what language? _____________________

 

El Michigan Department of Health and Human Services debe ayudar a todas las personas a completar la aplicacion cuando asi lo piden. Si usted necesita ayuda, por favor llame o visite a su especialist o la oicina el nombre debajo. Si necesita un interprete, el departmeto le proporcionará

uno gratis o usted puede usar uno de su eleccion. Si usted es negado ayuda para completar la aplicacion, puede llamar al 855-275-6424 o 855-789-5610.

¿Necesita que el Departamento proporcione un interprete para que le ayude en la entrevista? c si c no

Si dice que si, ¿en que idioma? __________________

.ﻚﻟذ ﻢﮭﻨﻣ ﺐﻠﻄﯾ ﺎﻣﺪﻨﻋ ،تارﺎﻤﺘﺳﻻا ءﻞﻤﻟ صﺎﺨﺷﻻا ﻊﯿﻤﺟ ةﺪﻋﺎﺴﻣ نﺎﻐﯿﺸﯿﻣ ﺔﯾﻻﻮﻟ ﺔﯿﻧﺎﺴﻧﻻاو ﺔﯿﺤﺼﻟا تﺎﻣﺪﺨﻟا ةرادا ﻰﻠﻋ ﺐﺠﯾ ﺔﺟﺎﺤﺑ ﺖﻨﻛ اذأ . هﺎﻧدا ﮫﻤﺳا دراﻮﻟا ﺐﺘﻜﻤﻟا وا ﻚﺘﻟﺎﺤﺑ ﺮﻈﻨﯾ يﺬﻟا ﻲﺋﺎﺼﺧﻻا ةرﺎﯾز وا لﺎﺼﺗﻻا ﻰﺟﺮﯾ ،ةﺪﻋﺎﺴﻤﻟا ﻰﻟا ﺔﺟﺎﺤﺑ ﺖﻨﻛ اذإ ،ﺐﻠﻄﻟا ءﻞﻤﺑ ﻚﺗﺪﻋﺎﺴﻣ ﺾﻓر ﻢﺗ اذا .ﺐﻏﺮﺗ ﻦﻣ رﺎﯿﺘﺧا ﻚﺘﻋﺎﻄﺘﺳﺎﺑ وأ ﻞﺑﺎﻘﻣ نوﺪﺑ ﻚﻟ ﻢﺟﺮﺘﻣ ﺮﯿﻓﻮﺘﺑ ةرادﻻا مﻮﻘﺘﺳ ، ﻢﺟﺮﺘﻣ ﻰﻟا

.855-789-5610 وا 855-275-6424: ﻲﻟﺎﺘﻟا ﻢﻗﺮﻟا ﻰﻠﻋ لﺎﺼﺗﻻا ﻚﻨﻜﻤﯾ

.

 

ﻻ

 

 

ﻢﻌﻧ ؟ ﺔﻠﺑﺎﻘﻤﻟا ءﺎﻨﺛا كﺪﻋﺎﺴﯾ ﻲﻛ ﺎﻤﺟﺮﺘﻣ ﻚﻟ ﺮﻓﻮﺗ نا ةرادﻻا ﻦﻣ ﻦﯾﺮﺗ ﻞھ

 

 

 

 

 

 

____________________ ؟ ﺎﮭﺑ ﻢﻠﻜﺘﺗ ﻲﺘﻟا ﺔﻐﻠﻟا ﻲھ ﺎﻤﻓ ﻢﻌﻨﺑ ﺖﺒﺟا اذإ

El Michigan Department of Health and Human Services (MDHHS) no discrimina contra ningún individuo o grupo a causa de su raza, religión, edad, origen nacional, color de piel, estatura, peso, estado matrimonial, información genética, sexo, orientación sexual, identidad de sexo o expresión, creencias políticas o incapacidad.

PLEASE READ CAREFULLY

FOR NURSING FACILITY PATIENTS ONLY

Complete this form if you are in a nursing facility. Please read each item carefully before you answer it. The answers you give will be used to determine if you are eligible for health care coverage. Be sure to sign your name on pages 2 and 4.

You can apply for health care coverage by mailing or having someone take this form into your local Michigan Department of Health and Human Services (MDHHS) ofice. Your application must be approved or denied

within:

•45 days, or

•90 days if disability is a factor in determining your health care coverage eligibility.

Use DCH-1426, Application for Health Coverage and Help Paying Costs, if other family members want help with medical expenses.

LOCAL OFFICE:

The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.

AUTHORITY:

42 CFR PART 435.

COMPLETION:

Voluntary.

PENALTY:

No Healthcare Coverage.

DHS-4574 (Rev. 5-16) Previous edition obsolete.

FOR OFFICE USE ONLY

NOTES

DHS-4574 (Rev. 5-16) Previous edition obsolete.

FOR OFFICE USE ONLY

NOTES

DHS-4574 (Rev. 5-16) Previous edition obsolete.

FOR OFFICE USE ONLY

NOTES

DHS-4574 (Rev. 5-16) Previous edition obsolete.

ASSETS DECLARATION

PATIENT AND SPOUSE

Michigan Department of Health and Human Services

(Skip if no spouse)

FOR OFFICE USE ONLY

Beneiciary Name

Client ID

Case Number

County

District

Section

Unit

Specialist

 

 

 

 

 

PLEASE PRINT

Patient’s Name (First, Middle, Last)

Phone No. of Nursing Home

Spouse’s Name (First, Middle, Last)

Spouse’s Phone No.

 

 

 

 

 

 

 

Address of Nursing Home (Number, Street, Rural Route)

 

Spouse’s Address (Number, Street, Rural Route)

 

 

 

 

 

 

 

City

State

 

Zip Code

City

State

Zip Code

 

 

 

 

 

 

Patient’s Birthdate (Mo/Day/Yr)

Patient’s Social Security

Spouse’s Birthdate (Mo/Day/Yr

Spouse’s Social Security*

 

 

 

 

 

 

 

This form asks questions about the property or assets owned by you and/or your spouse. This information is needed to determine your eligibility for Healthcare Coverage and the amount of assets that can be protected for the beneit of your spouse. Answer the following questions by providing information about all assets owned by you and/or your spouse as of _________________________.

Include assets you or your spouse own jointly with family or other persons.

ASSETS

1. Do you and/or your spouse have any assets (include assets held jointly)?

 

c Yes

4Check all types of assets your household has and complete the table

c No

c c c

Checking/draft account Certiicates of Deposit (CD)

Case on hand or in safe deposit

c c c

Money market accounts Christmas club accounts

Savings, bonds, stocks or mutual funds

c c c

Savings/share accounts

Patient trust fund

IRA, KEOGH, 401K or Deferred

Compensation account(s)

c Trust or Annuity

c Land contract, mortgage or other

 

notes payable to household member

cReal estate (including place you live)

c c c

Life estate/life lease

 

c Burial plot(s), casket, etc.

 

c Tools, equipment, livestock or crops

Life insurance

 

c Other Assets ___________________

c Health Savings Account

Burial trust/funeral contract(s)

 

 

 

 

 

 

 

 

Type(s)

 

 

Name and address

 

Account/policy

Owner(s)

 

 

Balance

 

of asset(s)

 

of Asset(s)

 

amount of value

(bank, insurance company, etc.)

 

number, etc.

 

 

 

 

 

 

 

 

 

 

 

The Michigan Department of Health and Human Services (MDHHS) does not

AUTHORITY:

42 CFR Part 435.

discriminate against any individual or group because of race, religion, age,

COMPLETION:

Voluntary.

national origin, color, height, weight, marital status, genetic information, sex,

PENALTY:

No Healthcare Coverage.

sexual orientation, gender identity or expression, political beliefs or disability.

*Optional if the community spouse is not requesting assistance.

DHS-4574-B (Rev. 5-16) Previous edition obsolete.

1

ASSETS

2. Does anyone in your household have any vehicles?

c Yes

4Check all types of assets your household has and complete the table

c No

c Car

c Truck c Boat

Owner(s)

(As shown on vehicle title

or registration)

c Camper/trailer

c Motorcycle

c RV

c Other Vehicle

Year

Make/Model

Amount Owed

 

 

 

3. Has anyone in your household:

•sold or given away property, land, vehicles, stocks, bonds, savings, cash, checking, income, etc., closed any accounts or removed or added a name on any asset within the last 60 months?

•iled a pending lawsuit which may bring money, property, etc.?

•received a one-time cash payment (such as worker’s compensation, lottery winnings, insurance settlement, lawsuit award, etc.) within the last 60 months?

•or has anyone acting for any household member, ever put any money, lawsuit settlement, income or assets in a trust, annuity or similar legal device?

c Yes 4Who:

cNo

cYes 4Who:

cNo

cYes 4Who:

cNo

cYes 4Who:

cNo

AFFIDAVIT

I swear or afirm that all the information that I have written on this form or told to a specialist is true. I understand that I can be prosecuted for perjury if I have intentionally given false information. I also know that I may be asked to show proof of any information I have given. I also know that if I have intentionally left out any information or if I have given false information, which causes me to receive assistance I am not entitled to or more assistance than I am entitled to, I can be prosecuted for fraud.

Estate Recovery. I understand that upon my death the Michigan Department of Health and Human Services (MDHHS) has the legal right to seek recovery from my estate for services paid by Healthcare Coverage. This means that some or all of my estate may be recovered. MDHHS will not seek to recover against the estate while there is a legal surviving spouse or a legal surviving child who is under the age of 21, blind, or disabled. An estate consists of real and personal property. If you have received an asset disregard due to a long-term care partnership policy, Estate Recovery applies to all assets whether they are subject to probate administration or not. Estate recovery only applies to certain Healthcare Coverage recipients who received Healthcare Coverage services after the effective date of the estate recovery statute. MDHHS may agree not to pursue recovery if an undue hardship exists. An application must be submitted to determine if the applicant qualiies for an undue hardship waiver. Undue hardship waivers are temporary. For further information regarding Estate Recovery, call 800-642-3195.

Signature (Patient or Representative)

Date (Month, Day, Year)

Two Witnesses Only If Signed by Mark X

Signature of First Witness

Signature of Second Witness

NOTE: If you signed this application on behalf of someone else, complete the information below.

Name (First, Middle, Last)

Phone Number

Relationship to Patient

Street Address

City

State

Zip Code

DHS-4574-B (Rev. 5-16) Previous edition obsolete.

2

Note: This application requests information about the patient in the nursing facility.

The words “You” and “Your” refer to the patient.

1.

Patient’s Name (First, Middle, Last)

 

 

 

 

2.

Name of Nursing Facility

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. Address of Nursing Facility

 

 

 

 

 

 

City

 

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

Phone No. of Nursing Facility

 

5. County

 

6.

Birthdate

7. Sex

 

8. Social Security Number

 

 

 

 

 

 

 

 

 

 

 

 

9.

Marital Status: c Never married

 

c Married

c Separated c Divorced

c Widowed

 

10. Date of Nursing Facility Admission

 

11. Address where you lived before you entered the nursing facility

 

 

 

 

 

 

 

 

 

 

 

 

 

 

12.If married, tell us about your spouse and all persons living with your spouse. If not married, tell us about your children under age 18 living in your home.

Name

Date of Birth

Social Security Number*

Relationship to you

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If you have a court-appointed guardian/conservator, enter information below:

 

 

 

 

 

 

 

 

13. Name of Guardian/Conservator

 

Phone Number

 

Do you pay guardian/conservator

 

 

 

 

 

expenses?

c YES

c NO

 

 

 

 

 

 

 

 

Guardian’s/Conservator’s Address

 

 

 

City

State

Zip Code

 

 

 

 

 

 

 

 

YES NO

14.Have you ever applied for or received

assistance in Michigan?

c

c

15.Have you received money or beneits such

as Medical Assistance from another state in the last 30 days?

c c

21.Do you have unpaid medical expenses for services provided in the last 3 months?

22.Do you pay health insurance premiums?

23.Do you have Medicare Coverage? Do you need help paying premiums?

YES NO

c c

c c

c c

c c

16.

Are you a U.S. citizen or U.S. national?

c

c

24.

Are you covered by a health, hospital, or

17.

If you are not a U.S. citizen or U.S. national, do you have

 

long-term care insurance policy or were you

 

covered in the last 3 months?

 

eligible immigration status? If Yes:

 

 

 

 

 

 

25. Has a court ordered anyone to pay your

 

a. Immigration document type ______________

 

 

b. Document ID number ___________________

 

 

medical expenses or provide health

 

c. Have you lived in the U.S. since 1996?

c

c

 

insurance for you?

 

d. Are you, or your spouse or parent a veteran or an

 

26.

Have you had an accident or work-related

 

active-duty member of the U.S. military?

c

c

 

 

illness or injury resulting in medical costs

 

e. U.S. entry date ______________________

 

 

 

 

 

that may be paid by another person or an

18.

Enter your racial heritage from codes below. If you are

 

 

insurance company?

 

 

 

 

multiracial, enter all the codes that apply (answering

 

 

 

 

is voluntary) I = American Indian, A = Alaskan Native,

 

27.

Have you set up a plan or entered into a

 

S = Asian, B = Black or African American,

P = Native

 

 

 

 

contract, such as a life care contract, that

 

Hawaiian or Other Paciic Islander, W = White

 

 

 

 

 

will pay for your medical care?

 

_____________________________

 

 

 

 

 

 

 

 

19.

Check the box if you are Hispanic or

 

 

28. Is there a plan for you to return home

 

Latino (answering is voluntary).

c

 

 

within six months from the date of

 

 

 

 

 

admittance?

20.

Are you a veteran or the spouse,

c

c

 

 

 

dependent or parent of a veteran?

 

 

*Optional if the community spouse and/or children are not applying for Healthcare Coverage.

c c

c c

c c

c c

c c

DHS-4574 (Rev. 5-16) Previous edition obsolete.

3

29.Assets: Complete the assets section by providing the requested asset information for you and your spouse. List your assets and your spouse’s assets. Include assets you own jointly with family or other persons, including your spouse. Include assets your spouse owns jointly with you, family or other persons. Each item must be answered YES or NO. If answered

YES, enter amount or current value and owner(s).

Type of Asset

YES NO

Amount or Value

Owner(s) of Asset

Has anyone in your household received a federal tax refund in the last 12 months?

Cash on hand, in a safety deposit box or

patient trust fund

Home, life estate/life lease

Real estate, not your home

Mortgage, land contract or other notes payable to you

Savings bonds or money market funds

Stocks or mutual funds

Pension, IRA, KEOGH, 401K or deferred

compensation account(s)

Trust funds

Life Insurance

Annuity

Cars, vans, trucks, campers, boats, snow- mobiles, other vehicles

Tools, equipment, livestock, or crops

Funeral contracts

Burial plot, casket, etc.

Health Savings Account

Are there any other assets? (Please Explain)

Checking/Draft Accounts — Savings/Share Accounts — Certiicates of Deposit

Name(s) on the Account

Name and Address of Bank

Credit Union, Savings and Loan

Account Number

Balance

YES NO

30.Have you received a one-time cash payment in the last 60 months (5 years) such as an insurance

settlement, lawsuit award, worker’s compensation, lottery winnings, etc.?

c

c

31. Do you have a pending lawsuit that may bring property or money to you?

c

c

32.Within the last 60 months (5 years) have you or a joint owner or other person whose name is also listed on the asset:

•

sold, given away, or transferred ownership in any asset such as those listed above?

c

c

•

removed or added a name on any asset such as those listed above?

c

c

33.Have you or someone acting for you ever put any money, income, lawsuit settlement or assets in a

trust, annuity or similar device?

c

c

DHS-4574 (Rev. 5-16) Previous edition obsolete.

4

34.Income: Include income for yourself and everyone listed in question 12.

Is anyone employed or self-employed? c YES c NO If YES, complete the following for each employed person.

 

Persons employed or

 

Employer name

 

Wages before

 

How often paid: weekly,

 

self-employed

 

 

 

 

deductions

 

every 2 wks, monthly, other

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

$

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Every item below must be answered YES or NO.

 

 

 

 

 

 

 

 

 

Type of Income

 

 

 

YES

NO

 

 

Amount

Whose Income

 

 

 

 

 

 

 

 

 

 

 

Social Security Beneits (RSDI) Claim #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Social Security Beneits (RSDI) Claim #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Supplemental Security Income (SSI)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Supplemental Security Income (SSI)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Retirement Beneits

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Veterans Beneits

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Disability Beneits

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Rental Income

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Worker’s Compensation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Child Support

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Unemployment Compensation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Military Allotments

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Gaming Distributions (Casino Proit Sharing)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Is there any other income? (Please explain)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

35.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address where your spouse lives

 

 

 

 

 

 

 

 

 

Spouse’s Phone Number

 

 

 

 

 

 

 

City

 

State

 

 

Zip Code

County

 

 

 

 

 

 

 

 

 

 

Household Expenses

Check YES or NO and write in the answer about you and/or your spouse’s home.

 

 

 

 

 

 

YES

 

NO

 

 

AMOUNT

HOW OFTEN PAID

 

 

 

 

 

 

 

 

 

 

Do you and/or your spouse have a rent, mortgage or other shelter

 

 

 

 

 

 

 

 

 

expense?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you and/or your spouse have the following expenses separate from rent or mortgage:

 

•

Renter’s Insurance

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

•

Property Taxes

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

• Mobile Home Lot Rent

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

•

Special Assessments

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

•

Homeowner’s Insurance

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

•

Mortgage Guarantee Insurance

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

• Cooperative or Condominium Fee

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Do you and/or your spouse have an obligation to pay for heat and/

 

 

 

 

 

 

 

 

 

or utilities?

 

 

 

 

 

 

 

 

 

 

DHS-4574 (Rev. 5-16) Previous edition obsolete.

5

ASSIGNMENT OF BENEFITS

Recovery of Medical Costs. I understand that when the Michigan Department of Health and Human Services

(MDHHS) pays the cost of hospital, surgical, or medical services, any right to recover costs from a third person or public or private contractor, except Medicare, is transferred to the MDHHS. Payment of any recovery under such right is to be made directly to the State of Michigan — MDHHS.

RELEASES

Social Security Information. I will allow the Social Security Administration to give to the MDHHS all information necessary to determine my eligibility for beneits under the Healthcare Coverage program until the second month following the expiration of my eligibility based on the current application.

Eligibility Information. I understand that the information I have provided will be used to determine my eligibility for Healthcare Coverage only and for purposes of administering the Healthcare Coverage program.

AFFIDAVIT

Under penalties of perjury, I swear that this application has been examined by or read to me, and, to the best of my knowledge, the facts are true and complete. If I am a third party applying on behalf of another person, I swear that this application has been examined by or read to the applicant, and, to the best of my knowledge, the facts are true and complete.

I certify, under penalty of perjury, that all information that I have written on this form or told to a specialist is true. I understand that I can be prosecuted for perjury if I have intentionally given false information. I also know that I may be asked to show proof of any information I have given. I also know that if I have intentionally left out any information or if I have given false information, which causes me to receive assistance I am not entitled to or more assistance that I am entitled to, I can be prosecuted for fraud. I understand I must report changes in income, assets or health insurance coverage to the department within 10 days of the change.

If you have any questions, contact your specialist or the local MDHHS before signing the application.

I understand that upon my death the Michigan Department of Health and Human Services (MDHHS) has the legal right to seek recovery from my estate for services paid by Healthcare Coverage. This means that some of all of my estate may be recovered. MDHHS will not seek to recover against the estate while there is a legal surviving spouse or a legal surviving child who is under the age of 21, blind, or disabled. An estate consists of real and personal property. If you have received an asset disregard due to a long-term care partnership policy, Estate Recovery applies to all assets whether they are subject to probate administration or not. Estate recovery only applies to certain Healthcare Coverage recipients who received Healthcare Coverage services after the effective date of the estate recovery statute. MDHHS may agree not to pursue recovery if an undue hardship exists. An application must be submitted to determine if the applicant qualiies for an undue hardship waiver. Undue hardship waivers are temporary. For further information regarding Estate Recovery, call 800-642-3195.

IMPORTANT: YOU MUST SIGN THE APPLICATION

I certify that I have received and reviewed a copy of the Acknowledgments that explains additional information about applying for and receiving Healthcare Coverage.

Signature (Patient or Representative)

Date

Two Witnesses only if signed by X

Date

 

 

1.

 

 

 

 

 

2.

 

 

 

 

 

 

 

Signature (Patient or Representative)

Date

Two Witnesses only if signed by X

Date

 

 

1.

 

 

 

 

 

2.

 

 

 

 

 

 

 

 

 

If you are signing this application on behalf of someone else, complete the information below.

Name of person completing application

Phone Number

Relationship to patient

 

 

 

 

Street Address

City

State

Zip Code

 

 

 

 

DHS-4574 (Rev. 5-16) Previous edition obsolete.

6

Similar forms

The Michigan DHS 4574 form, which serves as an application for health care coverage for patients in nursing facilities, shares similarities with several other important documents. Below are five such documents, each with a brief explanation of how they relate to the DHS 4574 form.

  • DCH-1426, Application for Health Coverage and Help Paying Costs: This document is used when other family members seek assistance with medical expenses. Like the DHS 4574, it collects information to determine eligibility for health care coverage but is broader in scope, accommodating family units rather than just individual nursing facility patients.
  • Medicaid Application Form: This form is essential for individuals seeking Medicaid benefits. Similar to the DHS 4574, it requires detailed financial information to assess eligibility for health care coverage based on income and assets. Both forms aim to ensure that applicants receive the necessary support for their health care needs.
  • Asset Declaration Form: Often used in conjunction with health care applications, this form gathers information about an applicant's assets. Like the DHS 4574, it plays a crucial role in determining eligibility for health care coverage, particularly for those in nursing facilities who may have spouses or family members to consider in the assessment.
  • Long-Term Care Application: This document is specifically designed for individuals seeking long-term care benefits. It shares similarities with the DHS 4574 in that both require comprehensive personal and financial information to evaluate eligibility for health care services, particularly for those requiring extended care.
  • Power of Attorney form - This vital document grants an agent the authority to make decisions on behalf of the principal, ensuring that personal wishes are respected, similar to the way the DHS 4574 facilitates health care applications. For more information and to fill out a Power of Attorney form, consider the importance of having trusted individuals in place to manage affairs when necessary.
  • Supplemental Security Income (SSI) Application: This application is for individuals seeking financial assistance due to disability or age. Like the DHS 4574, it assesses financial resources and eligibility for support, ensuring that those in need can access necessary health care services.

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For those needing to effectively manage the estate of a deceased individual, the process can be greatly facilitated by utilizing a Simple Small Estate Affidavit, which allows heirs to claim property without the complications of formal probate proceedings.

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Misconceptions

Understanding the Michigan DHS 4574 form is crucial for those seeking health care coverage in a nursing facility. However, several misconceptions can lead to confusion. Here are ten common misconceptions and clarifications regarding the form:

  1. It's only for nursing home patients. Many believe this form is exclusive to nursing home patients. In reality, it is specifically designed for patients in nursing facilities but can also apply to others seeking health care coverage.
  2. You must fill it out alone. Some think they have to complete the application without assistance. The Michigan Department of Health and Human Services (MDHHS) offers help to anyone who requests it.
  3. Help is only available in English. Many assume that assistance is only provided in English. MDHHS provides interpreters free of charge in various languages to help applicants understand the form.
  4. Submitting the form guarantees coverage. Some individuals believe that filling out the form ensures they will receive health care coverage. Approval is subject to eligibility criteria based on the information provided.
  5. It's a lengthy process. Many worry that the application process takes forever. In fact, MDHHS must approve or deny applications within 45 to 90 days, depending on the circumstances.
  6. All assets must be disclosed. Some think they need to report every single asset. While it's important to disclose relevant assets, there are protections for certain assets, especially those belonging to a spouse.
  7. There's a penalty for not completing it. Many fear there will be penalties for not filling out the form. While not applying can result in lack of coverage, there are no direct penalties for incomplete forms.
  8. You cannot apply if you have a spouse. Some believe that having a spouse disqualifies them from applying. This is incorrect; the form includes sections to report spousal information for eligibility assessment.
  9. Only low-income individuals can apply. Many think that only those with low income are eligible. However, eligibility can depend on various factors, not solely income.
  10. Once submitted, you cannot make changes. Some think they cannot amend their application after submission. You can update your application if circumstances change or if you realize you've made an error.

Being informed about these misconceptions can help streamline the application process and ensure that individuals receive the health care coverage they need.

Detailed Instructions for Using Michigan Dhs 4574

After completing the Michigan DHS 4574 form, the next step involves submitting it to your local Michigan Department of Health and Human Services office. Ensure that all required fields are filled out accurately to avoid delays in processing your application. The application will be reviewed, and you will receive a decision regarding your eligibility for health care coverage within the specified time frame.

  1. Begin by entering the beneficiary's name in the designated field.
  2. Provide the client ID and case number, if available.
  3. Fill in the county, district, section, and unit information as required.
  4. Indicate whether you need an interpreter during the interview by checking "Yes" or "No." If "Yes," specify the language needed.
  5. Complete the patient’s information, including their name, phone number, birthdate, and social security number.
  6. If applicable, fill out the spouse’s information, including their name, phone number, birthdate, and social security number.
  7. Provide the address of the nursing home, including the street address, city, state, and zip code.
  8. If the spouse resides at a different address, include their address details as well.
  9. Answer the question regarding assets by checking "Yes" or "No." If "Yes," check all types of assets your household has.
  10. For each type of asset, complete the table with the name and address of the asset holder, account or policy number, and the balance or value of the asset.
  11. Sign your name on pages 2 and 4 of the form to validate your application.
  12. Submit the completed form by mailing it or delivering it in person to your local MDHHS office.

Dos and Don'ts

When filling out the Michigan DHS 4574 form, it's essential to approach the process thoughtfully. Here are some helpful dos and don’ts to keep in mind:

  • Do read the instructions carefully before starting the form.
  • Do provide accurate and complete information about your assets.
  • Do sign your name on all required pages to validate your application.
  • Do seek assistance from the Michigan Department of Health and Human Services if needed.
  • Don't rush through the application; take your time to ensure accuracy.
  • Don't omit any relevant details about your financial situation.
  • Don't hesitate to ask for help if you encounter any difficulties.

Following these guidelines can help streamline your application process and ensure that you receive the assistance you need.