Nursing Home/Supportive Living Facility Redetermination ...: Fill out & sign online

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How to use or fill out Nursing Home/Supportive Living Facility Redetermination Report Form

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Click ‘Get Form’ to open it in the editor.
Begin with Section A: Income. Indicate your income sources by checking 'Yes' or 'No' for each option provided, including Social Security and Veterans Benefits. If you receive a salary, enter your employer's name and monthly amount.
Move to Section B: Resources. Check 'Yes' or 'No' for each resource type you possess, such as cash or savings accounts. Provide values where applicable.
In Section C: Transfer of Resources, disclose any transfers made in the past year. Fill in details about the resources transferred, including dates and reasons.
Proceed to Section D: Income Diversion. Answer questions regarding any income you provide to family members and indicate if you wish to continue this support.
Finally, complete Section E: Customer Statement and Signature. Ensure all information is accurate before signing and dating the form.

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