Font size
WorksheetsForms and Applications
Total questions: 22
Worksheet time: 11mins
Form 1277 is the _________________. This form verifies if the applicant plans to return home after a stay in the nursing home.
Intent to Return Home Statement
Never Return Home Statement
Home Away From Home Statement
FORM ____ is NOT required for 181 status, unless it is pending due to a pending application.
1283
3400-C
1282
The Income Trust packet includes Forms 905, 906 and 907. This packet is sent to applicant that
Have income ABOVE the limit.
Have income BELOW the limit.
Have NO income.
Application (a) is NOT recommended for nursing home or CLTC.
Application ____-_ is intended for beneficiaries with FULL and Active Medicaid Coverage in other programs.
3402-B
3400-B
3401-B
Turn Around Document (TAD)
Which is TRUE about a TAD?
TADs are mailed to providers on the 3rd Friday of each month.
TADs provide a current list of beneficiaries residing at the particular facility.
Both are TRUE.
Neither statement is TRUE
Forms and applications can be submitted:
online at SCDHHS.gov
by mail or in person at an SCDHHS county office
By telephone through SC Thrive
All of these methods
Form 1253 - Request for Financial Investigation
Which statement is TRUE about this form?
This form is sent to the FBI.
This form is never used.
This Form is used to request information from financial institutions on behalf of the applicant.
Form 1282 is the last page of BOTH the 3400 and 3401 application forms.
Agree
Disagree
Unsure
The NHPLC deals with 3 versions of Form 3229:
3229-A 3229-ME 3229-B-ME
Which form is sent to applicants who have MEDICARE as primary?
3229-A
3229-ME
3229-B-ME
Form 181 does not require a 1282 unless:
It's pending due to a pending application.
It NEVER requires a 1282.
Form 1766 A ME - Development of Burial Exclusion
If an applicant has a pre-need contract for funeral expenses, it is excluded from resources. Is a bank account specifically set aside for burial expenses excluded from resources?
Yes.
No. The bank account would count as a resource.
Form 1255 is used to verify personal property information that is not available through on-line searches. Examples include homes, mortgages, vehicles, etc. Where is a Form 1255 sent?
A Hospital
A Nursing Home
A county courthouse
A life insurance company
Form 932 is the Notice of Denial of Waiver Services or Nursing Home Care. It advises why the applicant is not eligible. If denied for missing information, the applicant has __ days to return the missing information.
15 days
45 days
30 days
Form 1272 is also used to request financial information. Where would a Form 1272 sent?
A hospital or other nursing facility
The applicants employer
The Social Security Administration
Application ____ is PREFERRED for nursing home applicants.
3401
3400
3402
This form verifies the type of Veterans Affairs (VA) income an applicant receives.
Form 1492 Veterans Statement
Form 1212
Request for Verification of Veterans Information
Form 1776
Veterans Affairs Income Verification
Form 1280 verifies the value of a policy upon death of an applicant and verifies the value of a policy at present. What type of insurance does Form 1280 verify?
Burial Insurance
Life Insurance
Health Insurance
Form 1233-ME, Medicaid Eligibility Checklist, advises what is needed to continue processing an application. An NHPLC CSR can give a __ day extension from the date on the form.
30
15
45
Form 945 is the Verification of Medicaid Form. What information is contained on this form?
Medicaid recipient's effective date and termination date
A Medicaid recipient's application date.
Date a Medicaid recipient's information was added to MEDS
All of the information in on Form 945.
This form is used by CLTC staff to approve the applicant's level of care. It DOES NOT advise on Medicaid coverage.
Form 867
Form 5309
Form 185
Form 943 is the Information Release Form. What is the purpose of this form?
To authorize a facility to receive 181 status.
To authorize a facility to receive application status.
To authorize a representative to obtain information from SCDHHS on an applicant.
To authorize SCDHHS to obtain information on an applicant from third party entities.
