Nursing Home/Supportive Living Facility Redetermination ... 2025

1. Click ‘Get Form’ to open it in the editor.
2. Begin with Section A: Income. Indicate your income sources by checking 'Yes' or 'No' for each option, including Social Security and Veterans Benefits. If you receive income from employment, provide your employer's name and address.
3. Move to Section B: Resources. Check 'Yes' or 'No' for each resource listed, such as cash and savings accounts. If you own property, answer additional questions regarding its status and income generation.
4. In Section C: Transfer of Resources, disclose any transfers made in the past year. Provide details about the resources transferred, including dates and values.
5. Complete Section D: Income Diversion if applicable. Indicate if you are diverting part of your income to family members and provide their information if so.
6. Finally, sign and date the form in Section E: Customer Statement and Signature, ensuring all information is accurate before submission.

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