Dhhs form 3400 b-2026

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The document is a form used to collect information for determining eligibility for Nursing Home, Institutional, or In-Home Care services. It requires detailed responses regarding the applicant's financial history, assets, and living situation over the past five years. Additionally, it includes sections on legal representation, income sources, property ownership, and potential estate recovery implications related to Medicaid services.

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Click ‘Get Form’ to open the DHHS Form 3400 B in the editor.
Begin by entering the name of the person needing assistance, along with their Social Security Number and Medicaid ID. Ensure accuracy as this information is crucial for eligibility determination.
Proceed to Section I, where you will answer questions regarding any financial transfers made in the past five years. If applicable, provide details about closed accounts and property transfers.
In Section II, indicate if anyone has Conservatorship or Power of Attorney for the applicant. This section may require additional documentation, so be prepared to upload relevant legal papers.
Complete all sections thoroughly, ensuring that you check all applicable boxes and provide necessary details about income sources and assets. Use our platform's features to easily navigate between sections.

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Versions	Form popularity	Fillable & printable
2020	4.8 Satisfied (128 Votes)
2016	4.4 Satisfied (197 Votes)
2013	4 Satisfied (31 Votes)

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3400b

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