DHS-4574, Application for Health Care Coverage Patient of Nursing Facility

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

APPLICATION FOR HEALTH CARE COVERAGE

PATIENT OF NURSING FACILITY

Michigan Department of Health and Human Services

FOR OFFICE USE ONLY

Beneciary Name

Client ID

Case Number

HELP IS AVAILABLE

County District Section Unit Specialist

The Michigan Department of Health and Human Services must help all persons ll out the application,

when requested. If you need help, please call or visit your specialist or the ofce 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 lling 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 (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) ofce. 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.

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.

LOCAL OFFICE:

AUTHORITY:

COMPLETION:

PENALTY:

42 CFR PART 435.

Voluntary.

No Healthcare Coverage.

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 ocina 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? __________________

تﺎﻣﺪﺨﻟا ةرادا ﻰﻠﻋ ﺐﺠﯾ ﺔﯿﻧﺎﺴﻧﻻاو ﺔﯿﺤﺼﻟاتارﺎﻤﺘﺳﻻا ءﻞﻤﻟ صﺎﺨﺷﻻا ﻊﯿﻤﺟ ةﺪﻋﺎﺴﻣ نﺎﻐﯿﺸﯿﻣ ﺔﯾﻻﻮﻟ، .ﻚﻟذ ﻢﮭﻨﻣ ﺐﻠﻄﯾ ﺎﻣﺪﻨﻋ

ﻲﺋﺎﺼﺧﻻا ةرﺎﯾز وا لﺎﺼﺗﻻا ﻰﺟﺮﯾ ،ةﺪﻋﺎﺴﻤﻟا ﻰﻟا ﺔﺟﺎﺤﺑ ﺖﻨﻛ اذإ ﺔﺟﺎﺤﺑ ﺖﻨﻛ اذأ . هﺎﻧدا ﮫﻤﺳا دراﻮﻟا ﺐﺘﻜﻤﻟا وا ﻚﺘﻟﺎﺤﺑ ﺮﻈﻨﯾ يﺬﻟا

ﻞﺑﺎﻘﻣ نوﺪﺑ ﻚﻟ ﻢﺟﺮﺘﻣ ﺮﯿﻓﻮﺘﺑ ةرادﻻا مﻮﻘﺘﺳ ، ﻢﺟﺮﺘﻣ ﻰﻟا ،ﺐﻠﻄﻟا ءﻞﻤﺑ ﻚﺗﺪﻋﺎﺴﻣ ﺾﻓر ﻢﺗ اذا .ﺐﻏﺮﺗ ﻦﻣ رﺎﯿﺘﺧا ﻚﺘﻋﺎﻄﺘﺳﺎﺑ وأ

: ﻲﻟﺎﺘﻟا ﻢﻗﺮﻟا ﻰﻠﻋ لﺎﺼﺗﻻا ﻚﻨﻜﻤﯾ6424-275-855 وا5610-789-855.

رادﻻا ﻦﻣ ﻦﯾﺮﺗ ﻞھﺔﻠﺑﺎﻘﻤﻟا ءﺎﻨﺛا كﺪﻋﺎﺴﯾ ﻲﻛ ﺎﻤﺟﺮﺘﻣ ﻚﻟ ﺮﻓﻮﺗ نا ة ؟ ﻢﻌﻧ

ﻻ .

ﺘﺗ ﻲﺘﻟا ﺔﻐﻠﻟا ﻲھ ﺎﻤﻓ ﻢﻌﻨﺑ ﺖﺒﺟا اذإ ﺎﮭﺑ ﻢﻠﻜ ؟____________________

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-B (Rev. 5-16) Previous edition obsolete. 1

ASSETS DECLARATION

PATIENT AND SPOUSE

Michigan Department of Health and Human Services

(Skip if no spouse)

FOR OFFICE USE ONLY

Beneciary 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 benet 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 Checking/draft account c Money market accounts c Savings/share accounts

c Certicates of Deposit (CD) c Christmas club accounts c Patient trust fund

c Case on hand or in safe deposit c Savings, bonds, stocks or mutual funds c IRA, KEOGH, 401K or Deferred

Compensation account(s)

c Trust or Annuity c Land contract, mortgage or other

notes payable to household member

c Real estate (including place you live)

c Life estate/life lease c Burial plot(s), casket, etc. c Tools, equipment, livestock or crops

c Life insurance c Other Assets ___________________ c Health Savings Account

c Burial trust/funeral contract(s)

Owner(s)

of asset(s)

Type(s)

of Asset(s)

Balance

amount of value

Name and address

(bank, insurance company, etc.)

Account/policy

number, etc.

AUTHORITY: 42 CFR Part 435.

COMPLETION: Voluntary.

PENALTY: No Healthcare Coverage.

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.

*Optional if the community spouse is not requesting assistance.

DHS-4574-B (Rev. 5-16) Previous edition obsolete. 2

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 c Camper/trailer c Motorcycle c RV c

Other Vehicle

Owner(s)

(As shown on vehicle title

or registration)

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?

c Yes 4Who:

c No

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

c Yes 4Who:

c No

• received a one-time cash payment (such as worker’s compensation,

lottery winnings, insurance settlement, lawsuit award, etc.) within the last

60 months?

c Yes 4Who:

c No

• 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:

c No

AFFIDAVIT

I swear or afrm 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 qualies 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 (Rev. 5-16) Previous edition obsolete.

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 YES NO

14. Have you ever applied for or received

assistance in Michigan?

c c

21. Do you have unpaid medical expenses for

services provided in the last 3 months?

c c

15. Have you received money or benets such

as Medical Assistance from another state

in the last 30 days?

c c

22. Do you pay health insurance premiums?

c c

23. Do you have Medicare Coverage?

Do you need help paying premiums?

16.

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

c c

24. Are you covered by a health, hospital, or

long-term care insurance policy or were you

covered in the last 3 months? c c

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

eligible immigration status? If Yes:

a. Immigration document type ______________

b. Document ID number ___________________

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

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

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

e. U.S. entry date ______________________

25. Has a court ordered anyone to pay your

medical expenses or provide health

insurance for you? c c

26. Have you had an accident or work-related

illness or injury resulting in medical costs

that may be paid by another person or an

insurance company?

c c

Enter your racial heritage from codes below. If you are

multiracial, enter all the codes that apply (answering

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

S = Asian, B = Black or African American, P = Native

Hawaiian or Other Pacic Islander, W = White

_____________________________

18.

27. Have you set up a plan or entered into a

contract, such as a life care contract, that

will pay for your medical care?

c c

19.

Check the box if you are Hispanic or

Latino (answering is voluntary).

28. Is there a plan for you to return home

within six months from the date of

admittance? c c

20.

Are you a veteran or the spouse,

dependent or parent of a veteran?

c c

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

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

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 — Certicates 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.

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

self-employed

Employer name Wages before

deductions

How often paid: weekly,

every 2 wks, monthly, other

Every item below must be answered YES or NO.

Type of Income

YES

NO Amount Whose Income

Social Security Benets (RSDI) Claim #

Supplemental Security Income (SSI)

Retirement Benets

Veterans Benets

Disability Benets

Rental Income

Worker’s Compensation

Child Support

Unemployment Compensation

Military Allotments

Gaming Distributions (Casino Prot 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.

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 benets 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 qualies 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

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.

PLEASE KEEP THIS PAGE.

Tear out along the dotted line.

INFORMATION ABOUT HEALTHCARE COVERAGE

Rules may have changed since this was printed. Check with your local MDHHS ofce.

“You” and “Your” below refer to the patient. “We” means the Michigan Department of Health and Human

Services.

If you need help with past, unpaid medical expenses, Healthcare Coverage may begin three months before you

apply. You can have Healthcare Coverage even if you are not a U.S. citizen. Coverage might be limited to just

emergency services. There are limits on the amount of income and assets you can have and be eligible for

Healthcare Coverage.

Receiving Healthcare Coverage Services

You must tell all your providers (doctors, hospital, pharmacy, etc.) that you have applied for Healthcare Coverage

before you receive any new medical services. Not all providers accept Healthcare Coverage. Choose a provider

who does accept Healthcare Coverage.

You must give your medical provider a copy of your mihealth card or approval letter as soon as it is received.

This letter tells when your eligibility began. Your providers need this information to receive prompt payment for

medical services provided to you. This information is needed to issue you a refund if you pay for a Healthcare

Coverage service before you received the approval letter.

We might approve Healthcare Coverage for up to 3 months before you applied. If we do, ask your providers to

bill Healthcare Coverage for any covered services you received during those months. If you paid for any of these

bills before you received the approval letter, ask your health providers if they will refund your money and bill

Healthcare Coverage. Providers are not required to do this, but many will.

Your providers must submit your bills to Healthcare Coverage within 12 months after the date you received the

services. If they wait more than 12 months, then Healthcare Coverage may not pay the bill unless the delay in

billing is because you had to le an appeal to get Healthcare Coverage benets.

Income

You meet the income test if your income is not enough to pay your medical expenses. Usually you will pay part

of your nursing facility expenses and Healthcare Coverage will pay the rest. If you have a spouse or children at

home, a portion of your income might be protected for them.

We count income such as Social Security benets, pensions, rent income and veterans benets.

Assets

Countable assets must be at or below the $2,000 asset limit at least part of each month for which Healthcare

Coverage is requested. If you have a spouse at home:

We count your assets and your spouse’s assets initially. We protect a substantial amount of assets for your

spouse. The remainder cannot exceed $2,000 for you to be eligible for Healthcare Coverage.

Once initial eligibility is established, we only count your assets. The asset limit is $2,000.

If your assets are more than the asset limit, you may become eligible for Healthcare Coverage if you use your

excess assets to pay some of your medical bills, living expenses, or other debts. You may be asked to verify

when and for what purposes you used your excess assets.

Healthcare Coverage might not pay for your care if you or your spouse transfer assets or income for less than

fair market value. We look at transfers that occur up to 60 months (5 years) before, or any time after, your rst

date of application for Healthcare Coverage while in a nursing facility.

Nursing Facility Eligibility (MDCH Publication 726) - explains eligibility for persons in or entering a nursing facility.

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.

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

ACKNOWLEDGMENTS

Michigan Department of Health and Human Services

This is your copy of your rights and responsibilities as an applicant for or recipient of Healthcare Coverage benets. By signing the

application you acknowledge that you understood your rights and responsibilities and that you applied only for Healthcare Coverage.

ASSIGNMENT OF BENEFITS

1. 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.

ACKNOWLEDGEMENTS

2. Non-discrimination. I understand that if I believe I have been

discriminated against because of race, sex, religion, age, national

origin, color, marital status, disability or political beliefs, I have

the right to le a complaint with the: Regional Manager, Region

V, Ofce for Civil Rights, U.S. Department of Health and Human

Services, 233 N. Michigan Ave., Chicago, IL 60601, 800-368-1019,

800-537-7697 TDD.

3. Reporting Changes. I understand that the department needs to

know about changes that may affect my Healthcare Coverage.

I will tell the department of any changes within 10 days of the

change. I understand that if I intentionally do not do this, I can be

prosecuted for fraud or perjury.

The types of changes that MUST be reported are:

• Receipt of or increase in income such as social security,

veterans benets, railroad retirement, pensions, retirement,

disability or sick benets.

• Discharge or move from the nursing facility to another living

arrangement.

• Changes in health or hospital insurance coverage or amount

of premiums.

• Any accident or work-related illness or injury where medical

costs may be paid by another person or an insurance

company.

• Another person or an insurance company has agreed to pay

my medical expenses or is ordered to by the court.

• Receipt of a sum of money.

• Receipt of an inheritance, bank account, or other property or

income from or on behalf of another person.

If you have any doubt about whether you should report a change

in circumstances, ask your local MDHHS.

4. Hearings. I understand that if I do not agree with any decision

made on any matter concerning my case I have the right to ask

for an Administrative Hearing. I understand that I can ask for

information about an Administrative Hearing by calling my local

MDHHS.

I understand that if I want someone else to request a hearing for me

or represent me in a hearing, that person must rst have written au-

thorization to do so unless that person is my attorney or my spouse.

The MDHHS Administrative Hearings must have one of the following:

• my original signed statement authorizing the person to

request a hearing, or

• a copy of the court order naming the person as my guardian

or conservator.

Otherwise, my hearing request will be denied.

5. Repayment of Benets. I understand that if I receive more

benets than I am entitled to receive, through my fault, I may have

to repay any extra benets.

6. Immigration Status. I understand that, as part of determining my

eligibility for Healthcare Coverage, information about me may be

submitted to the Bureau of Citizenship and Immigration Services in

order to verify my immigration status.

7. Investigations. I understand that my application might be one

of those chosen for a complete investigation and an MDHHS

representative might call on me and might contact other people

in order to verify my eligibility for assistance.

8. Computer Cross-checking. I understand that, as part of

determining my eligibility for Healthcare Coverage, information

I give on this application will be veried by computer cross-

checking with other public and private agencies.

Wages reported by my employer(s) to the Department of

Labor and Economic Growth will be checked against wage

information I report to the MDHHS. My Social Security Number

will be used to check this information. Throughout the year, my

Social Security Number will also be checked with other sources

such as the Internal Revenue Service (IRS), Unemployment

Compensation, and the Social Security Administration

concerning income or assets.

The information obtained through this cross-checking may

be veried through collateral contact when discrepancies are

found. The information may affect both my eligibility and the

level of my benets.

9. Medical Information. By signing this application, I understand

that the MDHHS may get and use* necessary medical

information about me or any of my wards or my minor children,

including any information relative to HIV, ARC or AIDS, if

applicable. This information will only be obtained and used as

necessary to determine eligibility for a specic program or for

other program administration purposes.

*Some examples of uses are with auditors, caregivers, etc. State

law (MCL 333.5131 (8)) provides that a person who shares HIV,

ARC or AIDS information except as authorized by this release

or by law may be found “guilty of a misdemeanor punishable

by imprisonment for not more than 1 year or a ne of not more

than $5,000.00, or both, and is liable in a civil action for actual

damages or $1,000.00, whichever is greater, and costs and

reasonable attorney fees.”

10. Social Security Information. I will allow the Social Security

Administration to give to the MDHHS all information necessary

to determine my right to benets under Healthcare Coverage

until the second month following the expiration of my eligibility

based on the current application.

11. 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.

12. 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

qualies for an undue hardship waiver. Undue hardship

waivers are temporary. For further information regarding Estate

Recovery, call 800-642-3195.