Eligibility Requirements If you have transitioned through the HOME Choice program after July 2019, y-2026

1. Click ‘Get Form’ to open it in the editor.
2. Begin by entering your personal information, including your name, Social Security Number, date of birth, and gender. Ensure all details are accurate for a smooth application process.
3. In the eligibility section, confirm that you have transitioned through the HOME Choice program after July 2019. If applicable, check the box indicating your current Medicaid approval and provide your Medicaid ID number.
4. Indicate your income sources by checking all that apply from the list provided. This is crucial for demonstrating financial support for ongoing expenses.
5. Answer questions regarding your long-term care facility stay and provide necessary details such as admission dates and facility contact information.
6. Review the responsibilities section carefully. Check each box to confirm your understanding and agreement before signing the application.

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