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The Michigan DHS 4574 form, known as the Application for Health Care Coverage for Patients of Nursing Facilities, plays a crucial role for individuals seeking healthcare coverage while residing in a nursing facility. This form is specifically designed to assess eligibility for health care benefits provided by the Michigan Department of Health and Human Services (MDHHS). It requires detailed information about the applicant, including personal details such as name, client ID, and case number, as well as data regarding assets and financial resources. The form emphasizes the importance of assistance, stating that MDHHS staff are available to help individuals complete the application if needed. Additionally, the document includes provisions for language interpretation services to ensure accessibility for non-English speakers. Applicants must carefully read and respond to each item, as the information provided will determine their eligibility for coverage. The form also outlines the timeline for application processing, indicating that decisions will be made within 45 days, or 90 days if disability is a factor. Furthermore, it highlights that the MDHHS does not discriminate based on various personal characteristics, ensuring fair treatment for all applicants. Completing the DHS 4574 form accurately is essential for those in nursing facilities seeking necessary healthcare coverage.

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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.

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➤ PDF File

Form Specifications

Fact Name Description
Form Purpose This form is used to apply for health care coverage for patients in nursing facilities in Michigan.
Governing Law The form is governed by 42 CFR Part 435, which outlines eligibility for Medicaid programs.
Assistance Availability The Michigan Department of Health and Human Services (MDHHS) provides assistance for completing the application upon request.
Interpreter Services MDHHS offers free interpreter services for applicants who need language assistance during the interview.
Application Timeline Applications must be approved or denied within 45 days, or 90 days if disability is a factor.
Voluntary Completion Filling out the form is voluntary, but failure to do so may result in no healthcare coverage.
Non-Discrimination Policy MDHHS does not discriminate based on race, religion, age, national origin, or other protected categories.
Asset Declaration The form requires information about the applicant's and spouse's assets to determine eligibility for coverage.

Michigan Dhs 4574: Usage Guidelines

Completing the Michigan DHS 4574 form is a crucial step for individuals residing in nursing facilities who are seeking health care coverage. After filling out the form, applicants will need to submit it to their local Michigan Department of Health and Human Services office. The office will then review the application and determine eligibility for health care coverage.

  1. Begin by entering the beneficiary's name, client ID, case number, county, district, section, and unit specialist at the top of the form.
  2. Indicate whether you need an interpreter for the interview by checking "Yes" or "No." If "Yes," specify the language required.
  3. Provide the patient's name, phone number of the nursing home, and the spouse's name and phone number (if applicable).
  4. Fill in the address of the nursing home, including the number, street, city, state, and zip code. Repeat this for the spouse's address, if applicable.
  5. Enter the patient's birthdate and social security number, followed by the spouse's birthdate and social security number (if applicable).
  6. Answer the question regarding assets by selecting "Yes" or "No." If "Yes," check all types of assets owned by you and/or your spouse and complete the asset table provided.
  7. In the asset table, list the type of asset, name and address of the institution (bank, insurance company, etc.), account or policy number, owner(s), and balance or value of the asset.
  8. Make sure to sign your name on pages 2 and 4 of the form.
  9. Review the completed form for accuracy and completeness before submission.
  10. Submit the form by mailing it or delivering it in person to your local Michigan Department of Health and Human Services office.

Your Questions, Answered

What is the Michigan DHS 4574 form?

The Michigan DHS 4574 form is an application specifically designed for individuals who are patients in nursing facilities seeking health care coverage. This form collects essential information to determine eligibility for health care assistance through the Michigan Department of Health and Human Services (MDHHS).

Who should fill out the DHS 4574 form?

This form should be completed by individuals residing in nursing facilities. If you or a loved one is in a nursing home and needs health care coverage, this is the appropriate form to use. It is important to read each section carefully to provide accurate information.

How do I submit the DHS 4574 form?

You can submit the completed form by mailing it to your local MDHHS office or by having someone deliver it in person. Ensure that all required sections are filled out completely to avoid delays in processing.

What happens after I submit the form?

Once you submit the DHS 4574 form, the MDHHS will review your application. They are required to approve or deny your application within 45 days, or within 90 days if your disability status is being evaluated. You will receive notification regarding your eligibility status once a decision has been made.

Can I get help filling out the form?

Yes, the MDHHS is committed to assisting individuals with the application process. If you need help, you can call or visit your specialist. Additionally, if you require an interpreter, the department will provide one free of charge to assist you during the interview process.

What if I am denied help with the application?

If you are refused assistance while trying to fill out the application, you can call the MDHHS at 855-275-6424 or 855-789-5610 for further support. It’s important to advocate for your right to receive help.

What information do I need to provide on the form?

The form requires detailed information about your assets and those of your spouse, if applicable. This includes bank accounts, real estate, life insurance, and any other financial resources. Accurate reporting of your assets is crucial for determining eligibility for health care coverage.

Is there a penalty for not completing the form?

Failure to complete the DHS 4574 form may result in not receiving health care coverage. It’s essential to fill out the application accurately and submit it on time to avoid any disruptions in health care assistance.

What should I do if I have more questions?

If you have additional questions or need clarification about the DHS 4574 form or the application process, you can reach out directly to your local MDHHS office. They can provide you with the necessary information and guidance to ensure that your application is processed smoothly.

Where can I find the DHS 4574 form?

The DHS 4574 form can be obtained from your local Michigan Department of Health and Human Services office or downloaded from their official website. Make sure you are using the most current version of the form to avoid any issues.

Common mistakes

  1. Incomplete Information: Many applicants fail to provide all required details, such as the patient’s full name, social security number, or birthdate. Missing this information can delay processing.

  2. Incorrect Case Number: Entering the wrong case number can lead to confusion and miscommunication with the Michigan Department of Health and Human Services (MDHHS). Always double-check this number.

  3. Neglecting to Sign: Some individuals forget to sign the application on the required pages. A missing signature can result in the application being considered incomplete.

  4. Ignoring Asset Reporting: Applicants often overlook the need to accurately report all assets, including jointly owned ones. This information is crucial for determining eligibility.

  5. Misunderstanding Eligibility Criteria: Many people do not fully understand the eligibility requirements for health care coverage. This misunderstanding can lead to incorrect information being provided on the form.

  6. Failing to Provide Contact Information: Not including a phone number or address for both the patient and spouse can hinder communication. Ensure all contact details are current and accurate.

  7. Not Seeking Assistance: Some applicants hesitate to ask for help when filling out the form. The MDHHS offers assistance, including interpreters, which can simplify the process.

Documents used along the form

The Michigan DHS 4574 form is an essential document for individuals seeking health care coverage while residing in a nursing facility. However, several other forms and documents often accompany this application to ensure a comprehensive assessment of eligibility and benefits. Here’s a brief overview of these related documents.

  • DCH-1426, Application for Health Coverage and Help Paying Costs: This form is used when other family members want assistance with medical expenses. It helps in evaluating the household's overall health care needs.
  • 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 determining eligibility for health care coverage and understanding the financial situation.
  • DHS-101, Application for Assistance: This form is a general application for various assistance programs offered by the Michigan Department of Health and Human Services. It can be used for multiple services beyond health care.
  • DHS-1171, Medical Needs Assessment: This assessment evaluates the medical needs of the applicant. It helps determine the level of care required and ensures appropriate services are provided.
  • DHS-4605, Health Care Coverage Information: This document provides detailed information about health care coverage options available to applicants, helping them make informed decisions.
  • DHS-4011, Verification of Income: This form is necessary to verify the income of the applicant and their household. It plays a significant role in determining eligibility for health care coverage.
  • DHS-3503, Client Rights and Responsibilities: This document outlines the rights and responsibilities of clients receiving services. Understanding these rights is vital for applicants to navigate the system effectively.
  • DHS-303, Notice of Case Action: After the application is processed, this notice informs the applicant of the decision regarding their health care coverage. It provides clarity on what to expect next.
  • DHS-150, Consent for Release of Information: This consent form allows the Michigan Department of Health and Human Services to obtain necessary information from other agencies or individuals to process the application.

Understanding these accompanying documents can greatly enhance the application process for health care coverage. Each form serves a specific purpose and collectively ensures that applicants receive the support and resources they need. For assistance, it is always advisable to reach out to a specialist or local office.

Similar forms

  • Application for Health Coverage (DCH-1426): This form is used by individuals seeking assistance with medical expenses for themselves or their family members. Like the DHS 4574, it determines eligibility for health care coverage but is broader in scope, covering additional family members.
  • Medicaid Application (Form MDHHS-1171): This application is specifically for those applying for Medicaid benefits. It shares similarities with the DHS 4574 in that both forms assess financial and personal information to determine eligibility for health care assistance.
  • Asset Declaration Form (DHS-4574-B): This document is used to declare assets for both the patient and spouse. It is closely related to the DHS 4574, as both forms require detailed financial disclosures to assess eligibility for health care coverage.
  • Long-Term Care Application (DHS-4574-LTC): This form is specifically designed for individuals seeking long-term care services. Similar to the DHS 4574, it evaluates the applicant's needs and financial situation to determine eligibility for care services.
  • Supplemental Nutrition Assistance Program (SNAP) Application: While primarily focused on food assistance, this application also requires personal and financial information. Like the DHS 4574, it aims to assess eligibility based on income and household circumstances.

Dos and Don'ts

When filling out the Michigan DHS 4574 form, there are important guidelines to follow. Here are five things you should and shouldn't do:

  • Do read each question carefully before answering.
  • Don't leave any questions blank; provide all required information.
  • Do ask for help if you are unsure about any part of the form.
  • Don't submit the form without signing it on pages 2 and 4.
  • Do ensure that you include all assets owned by you and your spouse.

Misconceptions

  • Misconception 1: The DHS 4574 form is only for individuals in nursing homes.

    • This form is specifically designed for patients in nursing facilities, but it can also be relevant for others seeking health care coverage under certain circumstances.

  • Misconception 2: Completing the form is optional.

    • While filling out the form is voluntary, it is necessary for determining eligibility for health care coverage. Not completing it may result in no coverage.

  • Misconception 3: Assistance is not available for completing the form.

    • The Michigan Department of Health and Human Services offers help for anyone needing assistance with the application process. This support includes providing interpreters if needed.

  • Misconception 4: The form can be submitted without any supporting documents.
  • Misconception 5: The form must be submitted in person.

    • While individuals can hand in the form at a local office, it is also permissible to mail it. This flexibility can ease the process for many applicants.

  • Misconception 6: There is no time limit for processing the application.

    • The Michigan Department of Health and Human Services has specific timelines. Applications are typically processed within 45 days, or 90 days if disability is a factor.

  • Misconception 7: Only the patient’s information is required.

    • The form may require information about the patient’s spouse, if applicable. This includes asset declarations that affect eligibility for coverage.

  • Misconception 8: The form is the same for everyone.

    • There are different versions of the application form tailored to specific needs and circumstances. It’s important to use the correct form for your situation.

  • Misconception 9: The application can be denied without a reason.

    • If an application is denied, the applicant is entitled to an explanation. Understanding the reasons can help in addressing any issues for future applications.

  • Misconception 10: Submitting the form guarantees coverage.

    • Filling out the form does not automatically ensure health care coverage. Eligibility is determined based on the information provided and existing guidelines.

Key takeaways

Filling out the Michigan DHS 4574 form can be a critical step for individuals seeking health care coverage while residing in a nursing facility. Here are some key takeaways to keep in mind:

  • Assistance is Available: The Michigan Department of Health and Human Services (MDHHS) is committed to helping individuals complete the application. If you require assistance, do not hesitate to reach out to your specialist or the designated office.
  • Interpreter Services: If you need an interpreter for the application process, MDHHS will provide one at no cost. You also have the option to use an interpreter of your choice.
  • Eligibility Determination: The information you provide on the form will be used to assess your eligibility for health care coverage. It is essential to answer all questions carefully and accurately.
  • Submission Process: You can submit the completed form by mailing it or having someone deliver it to your local MDHHS office. Timely submission is crucial, as your application must be processed within 45 days, or 90 days if disability is a factor.
  • Asset Declaration: The form requires details about your assets and those of your spouse, if applicable. This information is vital for determining eligibility and the protection of assets for your spouse's benefit.

Taking the time to understand these aspects can greatly enhance the application experience and ensure that you receive the support you need.