All Bold Fields are REQUIRED

Please Select One: My family member is currently in a nursing home Yes No My family member may be entering a nursing home Yes No I am preplanning for a family member Yes No Undecided Yes No Contact Information Your Name Address (City, State, Zip) Phone  Email  Best Time to Call? 9:00am - 11:00am 11:00am - 1:00pm 1:00pm - 3:00pm 3:00pm - 5:00pm 5:00pm - 7:00pm 7:00pm - 9:00pm   Potential Medicaid Applicant Information Name of family member Family member's Marital status Single Married Divorced Widowed City where family member resides Additional Information: Complete the questions for the family member applying for Nursing Home Medicaid Assistance in Florida. Monthly Income From All Sources Medicaid Applicant Spouse Social Security Retirement Pensions Annuity Income Other Income (IRA, VA, Long-Term Care Benefits) Has the family member gifted any assets in the last 3 years? Yes No   Confidentiality Statement: The information will be kept confidential and in no way will be disclosed to any other party. Note: items marked with * are required fields