Medicaid Application Documents

• Rent receipt and/or lease
• Utility bills (most current)
• Mortgage statement, property and school tax bills (most current)
• Two letters of residence, from other than relative, stating length of time at given address
• Letter from person you live with verifying that they supply room and board

• Pay stubs for previous eight weeks
• Unemployment insurance book
• Statement of rental and/or room and board income         
• Support payments divorce or separation papers
• Award letter and/or photocopy of check for the following benefits:

           a. Social Security
           b. Veterans
           c. Union pension
           d. Railroad retirement
           e. Insurance endowments
           f.  N.Y.S. disability
           g. Workers Compensation

• If self-employed; business book and records
• Tax returns for the past two years

• Bank books (including IRA, CD and money market accounts) for past 60 months including closed accounts with copy of title page
• Checking account each statement for the past 60 months (with copies of checks over $2000) statements
• Title page of Life insurance policies and a letter from carrier stating the current cash value
• Stocks and Bonds Certificates. If in a brokerage account, each statement for the past 60 months
• Real Estate Deeds
• Health and Accident insurance policies and latest premiums
• Medicare card
• Closing papers on property sale
• Deed to Burial Plot

• DSS 486 'Physician's Statement for Determination of Disability' (if under 65 in Nassau County)
• DMSB1 Long Placement Form (for Home Care in Nassau County)
• 517 Physician's Request for Home Health Aide (for Home Care in Nassau County)
• M11Q Request for Home Care (Home Care for New York City)

• Spousal Refusal, if applicable