Dss ea 240 2026

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The document is an application form for Long Term Care or related medical assistance from the Department of Social Services in South Dakota. It provides detailed instructions for applicants, requiring them to fill out personal information, living arrangements, medical history, financial resources, and insurance details. The form also includes sections for dependents and legal representation. Additionally, it outlines the verification process for eligibility and includes legal disclaimers regarding privacy, civil rights, and potential consequences of providing false information.

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Click ‘Get Form’ to open the dss ea 240 in the editor.
Begin by filling out your personal information in Section 1. Ensure you provide your full name, current address, and contact details accurately.
In Section 2, if applicable, provide details about your spouse, including their name and birth date. If they are deceased or divorced, include relevant dates.
Proceed to Section 3 to list any dependents. Fill in their names, dates of birth, and gross income sources.
In Section 4, detail your living arrangements. Indicate if you have shelter costs and specify the type and amount of expenses.
Complete Section 5 by providing information about your medical history and any unpaid medical bills from the past three months.
Finally, review all sections for accuracy before submitting. Use our platform's features to save or print the completed form for submission.

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Versions	Form popularity	Fillable & printable
2020	4.8 Satisfied (159 Votes)
2011	4.8 Satisfied (207 Votes)
2006	4 Satisfied (39 Votes)
2003	4.8 Satisfied (22 Votes)

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What assets are exempt from Medicaid in South Dakota?

South Dakota Medicaid Phone Listing Claims (Status, Payment Questions and Remittance Requests): Dental Claims Status: 877.841.1478. Recipient Eligibility Inquiries: Medicaid Fraud Hotline: 800.765.7867. Medicaid Recipient Hotline: 800.597.1603. Primary Care Provider () Program: 800.597.1603.

What is the income limit for Medicaid in South Dakota?

Asset Definition Exceptions In South Dakota IRAs / 401Ks, are counted. There are also non-countable (exempt) assets. Exemptions include personal belongings (i.e., clothing), household furnishings and appliances, an automobile, select prepaid funeral contracts, and generally ones primary home.

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