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MEDICAID QUESTIONNAIRE AND ASSIGNMENT - North Dakota

MEDICAID QUESTIONNAIRE AND ASSIGNMENT - North Dakota 2025

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The document is a Medicaid Questionnaire and Assignment form from the North Dakota Department of Human Services. It collects essential information from applicants regarding accidents or injuries for which Medicaid may have provided payment. The form requires details about the client, any involved family members, insurance coverage, legal actions, and workers' compensation claims. Additionally, it includes an assignment of benefits section where the applicant authorizes Medicaid to receive payments directly for medical services rendered.

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Click ‘Get Form’ to open the MEDICAID QUESTIONNAIRE AND ASSIGNMENT in our editor.
Begin with SECTION I - CLIENT INFORMATION. Fill in your full name, telephone number, mailing address, Medicaid case number, and ID number. Ensure all fields are completed accurately.
Answer the questions regarding any accidents or injuries. If applicable, provide details about other family members involved and any legal actions considered.
If the accident was a vehicle accident, proceed to SECTION II. Indicate your role (driver, passenger, pedestrian) and provide insurance details as required.
For other types of accidents or workers' compensation claims, complete SECTIONS III and IV respectively. Include employer information and injury specifics where necessary.
Finally, review the MEDICAID ASSIGNMENT OF BENEFITS section. Sign and date the form to confirm your understanding and agreement.

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Got questions?

We have answers to the most popular questions from our customers. If you can't find an answer to your question, please contact us.

What is the look back period for Medicaid in North Dakota?

In North Dakota, the Look-Back Period is 60 months, which means the state will look back into the applicants financial history for the 60 months prior to their application date to see if they have given away any assets or sold them at less than fair market value.

What is the income limit for Medicaid in the ND?

Apply for Medicaid in North Dakota Also, adults are eligible with household incomes up to 138% of poverty, and pregnant women with incomes up to 147% of poverty. Children are eligible for Medicaid or CHIP with with household incomes up to 170% of poverty.

What assets are exempt from Medicaid in North Dakota?

Asset Definition Exceptions Exemptions include personal belongings, such as clothing, household furnishings, an automobile, irrevocable itemized burial contracts, and generally ones primary home. In North Dakota, IRAs and 401Ks are also exempt if they are in payout status.

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