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Free Michigan Dhs 4574 Template in PDF

The Michigan DHS 4574 form is an application designed for individuals residing in nursing facilities who seek health care coverage through the Michigan Department of Health and Human Services. This form assists the department in evaluating eligibility based on various factors, including income and assets. Understanding how to complete this application can significantly impact access to necessary health services.

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Structure

The Michigan DHS 4574 form is a crucial document for individuals residing in nursing facilities who seek health care coverage. This application serves as a means to assess eligibility for health care benefits provided by the Michigan Department of Health and Human Services (MDHHS). It is designed to collect essential information about the applicant and their spouse, if applicable, including personal details, contact information, and asset declarations. The form emphasizes the importance of assistance, offering help to anyone who requests it, including the provision of interpreters at no cost. It is vital for applicants to understand that their responses will influence the determination of their eligibility for health care coverage. Applicants must complete the form carefully, ensuring that they sign on the required pages. The MDHHS commits to processing applications within specified timeframes, either 45 days or 90 days if disability is a factor. This form represents not just a bureaucratic requirement, but a pathway to necessary medical support for those in need, reflecting the state's commitment to inclusivity and accessibility in health care services.

Form Example

APPLICATION FOR HEALTH CARE COVERAGE

PATIENT OF NURSING FACILITY

Michigan Department of Health and Human Services

HELP IS AVAILABLE

FOR OFFICE USE ONLY

Beneiciary Name

Client ID

Case Number

County	District	Section	Unit	Specialist

The Michigan Department of Health and Human Services must help all persons ill out the application, when requested. If you need help, please call or visit your specialist or the ofice named below. If you need an interpreter, the Department will provide one free of charge or you may use one of your choice. If you are refused help in illing out the application, call 855-275-6424 or 855-789-5610.

Do you need the Department to provide an interpreter to help you at the interview? c Yes	c No
If yes, what language? _____________________

El Michigan Department of Health and Human Services debe ayudar a todas las personas a completar la aplicacion cuando asi lo piden. Si usted necesita ayuda, por favor llame o visite a su especialist o la oicina el nombre debajo. Si necesita un interprete, el departmeto le proporcionará

uno gratis o usted puede usar uno de su eleccion. Si usted es negado ayuda para completar la aplicacion, puede llamar al 855-275-6424 o 855-789-5610.

¿Necesita que el Departamento proporcione un interprete para que le ayude en la entrevista? c si c no

Si dice que si, ¿en que idioma? __________________

.ﻚﻟذ ﻢﮭﻨﻣ ﺐﻠﻄﯾ ﺎﻣﺪﻨﻋ ،تارﺎﻤﺘﺳﻻا ءﻞﻤﻟ صﺎﺨﺷﻻا ﻊﯿﻤﺟ ةﺪﻋﺎﺴﻣ نﺎﻐﯿﺸﯿﻣ ﺔﯾﻻﻮﻟ ﺔﯿﻧﺎﺴﻧﻻاو ﺔﯿﺤﺼﻟا تﺎﻣﺪﺨﻟا ةرادا ﻰﻠﻋ ﺐﺠﯾ ﺔﺟﺎﺤﺑ ﺖﻨﻛ اذأ . هﺎﻧدا ﮫﻤﺳا دراﻮﻟا ﺐﺘﻜﻤﻟا وا ﻚﺘﻟﺎﺤﺑ ﺮﻈﻨﯾ يﺬﻟا ﻲﺋﺎﺼﺧﻻا ةرﺎﯾز وا لﺎﺼﺗﻻا ﻰﺟﺮﯾ ،ةﺪﻋﺎﺴﻤﻟا ﻰﻟا ﺔﺟﺎﺤﺑ ﺖﻨﻛ اذإ ،ﺐﻠﻄﻟا ءﻞﻤﺑ ﻚﺗﺪﻋﺎﺴﻣ ﺾﻓر ﻢﺗ اذا .ﺐﻏﺮﺗ ﻦﻣ رﺎﯿﺘﺧا ﻚﺘﻋﺎﻄﺘﺳﺎﺑ وأ ﻞﺑﺎﻘﻣ نوﺪﺑ ﻚﻟ ﻢﺟﺮﺘﻣ ﺮﯿﻓﻮﺘﺑ ةرادﻻا مﻮﻘﺘﺳ ، ﻢﺟﺮﺘﻣ ﻰﻟا

.855-789-5610 وا 855-275-6424: ﻲﻟﺎﺘﻟا ﻢﻗﺮﻟا ﻰﻠﻋ لﺎﺼﺗﻻا ﻚﻨﻜﻤﯾ

.	ﻻ		ﻢﻌﻧ ؟ ﺔﻠﺑﺎﻘﻤﻟا ءﺎﻨﺛا كﺪﻋﺎﺴﯾ ﻲﻛ ﺎﻤﺟﺮﺘﻣ ﻚﻟ ﺮﻓﻮﺗ نا ةرادﻻا ﻦﻣ ﻦﯾﺮﺗ ﻞھ

		____________________ ؟ ﺎﮭﺑ ﻢﻠﻜﺘﺗ ﻲﺘﻟا ﺔﻐﻠﻟا ﻲھ ﺎﻤﻓ ﻢﻌﻨﺑ ﺖﺒﺟا اذإ

El Michigan Department of Health and Human Services (MDHHS) no discrimina contra ningún individuo o grupo a causa de su raza, religión, edad, origen nacional, color de piel, estatura, peso, estado matrimonial, información genética, sexo, orientación sexual, identidad de sexo o expresión, creencias políticas o incapacidad.

PLEASE READ CAREFULLY

FOR NURSING FACILITY PATIENTS ONLY

Complete this form if you are in a nursing facility. Please read each item carefully before you answer it. The answers you give will be used to determine if you are eligible for health care coverage. Be sure to sign your name on pages 2 and 4.

You can apply for health care coverage by mailing or having someone take this form into your local Michigan Department of Health and Human Services (MDHHS) ofice. Your application must be approved or denied

within:

•45 days, or

•90 days if disability is a factor in determining your health care coverage eligibility.

Use DCH-1426, Application for Health Coverage and Help Paying Costs, if other family members want help with medical expenses.

LOCAL OFFICE:

The Michigan Department of Health and Human Services (MDHHS) does not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs or disability.

AUTHORITY:	42 CFR PART 435.
COMPLETION:	Voluntary.
PENALTY:	No Healthcare Coverage.

DHS-4574 (Rev. 5-16) Previous edition obsolete.

FOR OFFICE USE ONLY

NOTES

DHS-4574 (Rev. 5-16) Previous edition obsolete.

FOR OFFICE USE ONLY

NOTES

DHS-4574 (Rev. 5-16) Previous edition obsolete.

FOR OFFICE USE ONLY

NOTES

DHS-4574 (Rev. 5-16) Previous edition obsolete.

ASSETS DECLARATION

PATIENT AND SPOUSE

Michigan Department of Health and Human Services

(Skip if no spouse)

FOR OFFICE USE ONLY

Beneiciary Name

Client ID

Case Number

County	District	Section	Unit	Specialist

PLEASE PRINT

Patient’s Name (First, Middle, Last)	Phone No. of Nursing Home		Spouse’s Name (First, Middle, Last)	Spouse’s Phone No.

Address of Nursing Home (Number, Street, Rural Route)			Spouse’s Address (Number, Street, Rural Route)

City	State	Zip Code	City	State	Zip Code

Patient’s Birthdate (Mo/Day/Yr)	Patient’s Social Security		Spouse’s Birthdate (Mo/Day/Yr	Spouse’s Social Security*

This form asks questions about the property or assets owned by you and/or your spouse. This information is needed to determine your eligibility for Healthcare Coverage and the amount of assets that can be protected for the beneit of your spouse. Answer the following questions by providing information about all assets owned by you and/or your spouse as of _________________________.

Include assets you or your spouse own jointly with family or other persons.

ASSETS

1. Do you and/or your spouse have any assets (include assets held jointly)?
c Yes	4Check all types of assets your household has and complete the table	c No

c c c

Checking/draft account Certiicates of Deposit (CD)

Case on hand or in safe deposit

c c c

Money market accounts Christmas club accounts

Savings, bonds, stocks or mutual funds

c c c

Savings/share accounts

Patient trust fund

IRA, KEOGH, 401K or Deferred

Compensation account(s)

c Trust or Annuity	c Land contract, mortgage or other
	notes payable to household member

cReal estate (including place you live)

c c c

Life estate/life lease		c Burial plot(s), casket, etc.			c Tools, equipment, livestock or crops
Life insurance		c Other Assets ___________________			c Health Savings Account
Burial trust/funeral contract(s)
	Type(s)			Name and address		Account/policy
Owner(s)	Type(s)		Balance	Name and address		Account/policy
of asset(s)	of Asset(s)		amount of value	(bank, insurance company, etc.)		number, etc.

		The Michigan Department of Health and Human Services (MDHHS) does not
AUTHORITY:	42 CFR Part 435.	discriminate against any individual or group because of race, religion, age,
COMPLETION:	Voluntary.	national origin, color, height, weight, marital status, genetic information, sex,
PENALTY:	No Healthcare Coverage.	sexual orientation, gender identity or expression, political beliefs or disability.

*Optional if the community spouse is not requesting assistance.

DHS-4574-B (Rev. 5-16) Previous edition obsolete.

ASSETS

2. Does anyone in your household have any vehicles?

c Yes

4Check all types of assets your household has and complete the table

c No

c Car

c Truck c Boat

Owner(s)

(As shown on vehicle title

or registration)

c Camper/trailer

c Motorcycle

c RV

c Other Vehicle

Year	Make/Model	Amount Owed

3. Has anyone in your household:

•sold or given away property, land, vehicles, stocks, bonds, savings, cash, checking, income, etc., closed any accounts or removed or added a name on any asset within the last 60 months?

•iled a pending lawsuit which may bring money, property, etc.?

•received a one-time cash payment (such as worker’s compensation, lottery winnings, insurance settlement, lawsuit award, etc.) within the last 60 months?

•or has anyone acting for any household member, ever put any money, lawsuit settlement, income or assets in a trust, annuity or similar legal device?

c Yes 4Who:

cNo

cYes 4Who:

cNo

cYes 4Who:

cNo

cYes 4Who:

cNo

AFFIDAVIT

I swear or afirm that all the information that I have written on this form or told to a specialist is true. I understand that I can be prosecuted for perjury if I have intentionally given false information. I also know that I may be asked to show proof of any information I have given. I also know that if I have intentionally left out any information or if I have given false information, which causes me to receive assistance I am not entitled to or more assistance than I am entitled to, I can be prosecuted for fraud.

Estate Recovery. I understand that upon my death the Michigan Department of Health and Human Services (MDHHS) has the legal right to seek recovery from my estate for services paid by Healthcare Coverage. This means that some or all of my estate may be recovered. MDHHS will not seek to recover against the estate while there is a legal surviving spouse or a legal surviving child who is under the age of 21, blind, or disabled. An estate consists of real and personal property. If you have received an asset disregard due to a long-term care partnership policy, Estate Recovery applies to all assets whether they are subject to probate administration or not. Estate recovery only applies to certain Healthcare Coverage recipients who received Healthcare Coverage services after the effective date of the estate recovery statute. MDHHS may agree not to pursue recovery if an undue hardship exists. An application must be submitted to determine if the applicant qualiies for an undue hardship waiver. Undue hardship waivers are temporary. For further information regarding Estate Recovery, call 800-642-3195.

Signature (Patient or Representative)

Date (Month, Day, Year)

Two Witnesses Only If Signed by Mark X

Signature of First Witness

Signature of Second Witness

NOTE: If you signed this application on behalf of someone else, complete the information below.

Name (First, Middle, Last)

Phone Number

Relationship to Patient

Street Address

City

State

Zip Code

DHS-4574-B (Rev. 5-16) Previous edition obsolete.

Note: This application requests information about the patient in the nursing facility.

The words “You” and “Your” refer to the patient.

Patient’s Name (First, Middle, Last)

Name of Nursing Facility

3. Address of Nursing Facility

City

State

Zip Code

Phone No. of Nursing Facility

5. County

Birthdate

7. Sex

8. Social Security Number

Marital Status: c Never married

c Married

c Separated c Divorced

c Widowed

10. Date of Nursing Facility Admission

11. Address where you lived before you entered the nursing facility

12.If married, tell us about your spouse and all persons living with your spouse. If not married, tell us about your children under age 18 living in your home.

Name	Date of Birth		Social Security Number*			Relationship to you




If you have a court-appointed guardian/conservator, enter information below:

13. Name of Guardian/Conservator		Phone Number			Do you pay guardian/conservator
					expenses?	c YES	c NO

Guardian’s/Conservator’s Address				City		State	Zip Code

YES NO

14.Have you ever applied for or received

assistance in Michigan?

15.Have you received money or beneits such

as Medical Assistance from another state in the last 30 days?

c c

21.Do you have unpaid medical expenses for services provided in the last 3 months?

22.Do you pay health insurance premiums?

23.Do you have Medicare Coverage? Do you need help paying premiums?

YES NO

c c

16.	Are you a U.S. citizen or U.S. national?	c	c	24.	Are you covered by a health, hospital, or
17.	If you are not a U.S. citizen or U.S. national, do you have				long-term care insurance policy or were you
17.	If you are not a U.S. citizen or U.S. national, do you have				covered in the last 3 months?
	eligible immigration status? If Yes:				covered in the last 3 months?
	eligible immigration status? If Yes:			25. Has a court ordered anyone to pay your
	a. Immigration document type ______________			25. Has a court ordered anyone to pay your
	b. Document ID number ___________________				medical expenses or provide health
	c. Have you lived in the U.S. since 1996?	c	c		insurance for you?
	d. Are you, or your spouse or parent a veteran or an			26.	Have you had an accident or work-related
	active-duty member of the U.S. military?	c	c	26.	Have you had an accident or work-related
	active-duty member of the U.S. military?	c	c		illness or injury resulting in medical costs
	e. U.S. entry date ______________________				illness or injury resulting in medical costs
	e. U.S. entry date ______________________				that may be paid by another person or an
18.	Enter your racial heritage from codes below. If you are				insurance company?
18.	Enter your racial heritage from codes below. If you are
	multiracial, enter all the codes that apply (answering
	is voluntary) I = American Indian, A = Alaskan Native,			27.	Have you set up a plan or entered into a
	S = Asian, B = Black or African American,	P = Native		27.	Have you set up a plan or entered into a
	S = Asian, B = Black or African American,	P = Native			contract, such as a life care contract, that
	Hawaiian or Other Paciic Islander, W = White				contract, such as a life care contract, that
	Hawaiian or Other Paciic Islander, W = White				will pay for your medical care?
	_____________________________				will pay for your medical care?
	_____________________________
19.	Check the box if you are Hispanic or			28. Is there a plan for you to return home
	Latino (answering is voluntary).	c			within six months from the date of
					admittance?
20.	Are you a veteran or the spouse,	c	c
	dependent or parent of a veteran?	c	c

*Optional if the community spouse and/or children are not applying for Healthcare Coverage.

c c

DHS-4574 (Rev. 5-16) Previous edition obsolete.

29.Assets: Complete the assets section by providing the requested asset information for you and your spouse. List your assets and your spouse’s assets. Include assets you own jointly with family or other persons, including your spouse. Include assets your spouse owns jointly with you, family or other persons. Each item must be answered YES or NO. If answered

YES, enter amount or current value and owner(s).

Type of Asset

YES NO

Amount or Value

Owner(s) of Asset

Has anyone in your household received a federal tax refund in the last 12 months?

Cash on hand, in a safety deposit box or

patient trust fund

Home, life estate/life lease

Real estate, not your home

Mortgage, land contract or other notes payable to you

Savings bonds or money market funds

Stocks or mutual funds

Pension, IRA, KEOGH, 401K or deferred

compensation account(s)

Trust funds

Life Insurance

Annuity

Cars, vans, trucks, campers, boats, snow- mobiles, other vehicles

Tools, equipment, livestock, or crops

Funeral contracts

Burial plot, casket, etc.

Health Savings Account

Are there any other assets? (Please Explain)

Checking/Draft Accounts — Savings/Share Accounts — Certiicates of Deposit

Name(s) on the Account

Name and Address of Bank

Credit Union, Savings and Loan

Account Number

Balance

YES NO

30.Have you received a one-time cash payment in the last 60 months (5 years) such as an insurance

settlement, lawsuit award, worker’s compensation, lottery winnings, etc.?	c	c
31. Do you have a pending lawsuit that may bring property or money to you?	c	c

32.Within the last 60 months (5 years) have you or a joint owner or other person whose name is also listed on the asset:

•	sold, given away, or transferred ownership in any asset such as those listed above?	c	c
•	removed or added a name on any asset such as those listed above?	c	c

33.Have you or someone acting for you ever put any money, income, lawsuit settlement or assets in a

trust, annuity or similar device?

DHS-4574 (Rev. 5-16) Previous edition obsolete.

34.Income: Include income for yourself and everyone listed in question 12.

Is anyone employed or self-employed? c YES c NO If YES, complete the following for each employed person.

Persons employed or

Employer name

Wages before

How often paid: weekly,

self-employed

deductions

every 2 wks, monthly, other

Every item below must be answered YES or NO.

Type of Income

YES

Amount

Whose Income

Social Security Beneits (RSDI) Claim #

Supplemental Security Income (SSI)

Retirement Beneits

Veterans Beneits

Disability Beneits

Rental Income

Worker’s Compensation

Child Support

Unemployment Compensation

Military Allotments

Gaming Distributions (Casino Proit Sharing)

Is there any other income? (Please explain)

35.

Address where your spouse lives

Spouse’s Phone Number

City

State

Zip Code

County

Household Expenses

Check YES or NO and write in the answer about you and/or your spouse’s home.

YES

AMOUNT

HOW OFTEN PAID

Do you and/or your spouse have a rent, mortgage or other shelter

expense?

Do you and/or your spouse have the following expenses separate from rent or mortgage:

•

Renter’s Insurance

•

Property Taxes

• Mobile Home Lot Rent

•

Special Assessments

•

Homeowner’s Insurance

•

Mortgage Guarantee Insurance

• Cooperative or Condominium Fee

Do you and/or your spouse have an obligation to pay for heat and/

or utilities?

DHS-4574 (Rev. 5-16) Previous edition obsolete.

ASSIGNMENT OF BENEFITS

Recovery of Medical Costs. I understand that when the Michigan Department of Health and Human Services

(MDHHS) pays the cost of hospital, surgical, or medical services, any right to recover costs from a third person or public or private contractor, except Medicare, is transferred to the MDHHS. Payment of any recovery under such right is to be made directly to the State of Michigan — MDHHS.

RELEASES

Social Security Information. I will allow the Social Security Administration to give to the MDHHS all information necessary to determine my eligibility for beneits under the Healthcare Coverage program until the second month following the expiration of my eligibility based on the current application.

Eligibility Information. I understand that the information I have provided will be used to determine my eligibility for Healthcare Coverage only and for purposes of administering the Healthcare Coverage program.

AFFIDAVIT

Under penalties of perjury, I swear that this application has been examined by or read to me, and, to the best of my knowledge, the facts are true and complete. If I am a third party applying on behalf of another person, I swear that this application has been examined by or read to the applicant, and, to the best of my knowledge, the facts are true and complete.

I certify, under penalty of perjury, that all information that I have written on this form or told to a specialist is true. I understand that I can be prosecuted for perjury if I have intentionally given false information. I also know that I may be asked to show proof of any information I have given. I also know that if I have intentionally left out any information or if I have given false information, which causes me to receive assistance I am not entitled to or more assistance that I am entitled to, I can be prosecuted for fraud. I understand I must report changes in income, assets or health insurance coverage to the department within 10 days of the change.

If you have any questions, contact your specialist or the local MDHHS before signing the application.

I understand that upon my death the Michigan Department of Health and Human Services (MDHHS) has the legal right to seek recovery from my estate for services paid by Healthcare Coverage. This means that some of all of my estate may be recovered. MDHHS will not seek to recover against the estate while there is a legal surviving spouse or a legal surviving child who is under the age of 21, blind, or disabled. An estate consists of real and personal property. If you have received an asset disregard due to a long-term care partnership policy, Estate Recovery applies to all assets whether they are subject to probate administration or not. Estate recovery only applies to certain Healthcare Coverage recipients who received Healthcare Coverage services after the effective date of the estate recovery statute. MDHHS may agree not to pursue recovery if an undue hardship exists. An application must be submitted to determine if the applicant qualiies for an undue hardship waiver. Undue hardship waivers are temporary. For further information regarding Estate Recovery, call 800-642-3195.

IMPORTANT: YOU MUST SIGN THE APPLICATION

I certify that I have received and reviewed a copy of the Acknowledgments that explains additional information about applying for and receiving Healthcare Coverage.

Signature (Patient or Representative)	Date	Two Witnesses only if signed by X	Date
		1.
		2.

Signature (Patient or Representative)	Date	Two Witnesses only if signed by X	Date
		1.
		2.

If you are signing this application on behalf of someone else, complete the information below.

Name of person completing application	Phone Number	Relationship to patient

Street Address	City	State	Zip Code

DHS-4574 (Rev. 5-16) Previous edition obsolete.

▼ Michigan Dhs 4574 PDF Form

Document Specs

Fact Name	Details
Purpose	The DHS-4574 form is used to apply for health care coverage for patients residing in nursing facilities in Michigan.
Assistance Availability	The Michigan Department of Health and Human Services provides assistance in completing the form upon request.
Eligibility Determination	Eligibility for health care coverage is determined based on the information provided in the application. Approval or denial occurs within 45 to 90 days.
Governing Law	This form is governed by 42 CFR Part 435, which outlines federal regulations for Medicaid eligibility.

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