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The Michigan DHS 4574 form plays a pivotal role in ensuring healthcare coverage for nursing facility patients within the state, representing a crucial interface between applicants and the Department of Health and Human Services (MDHHS). This document facilitates the application process for individuals seeking health care assistance, underscoring the state's commitment to accessible healthcare services regardless of a person's background. Emphasizing the importance of inclusivity, the form explicitly states MDHHS's policy against discrimination based on race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs, or disability. It offers comprehensive guidance on how patients in nursing facilities can apply for health care coverage, highlighting the availability of help for filling out the application and the provision of interpreters at no cost to the applicant. The form also outlines the expected timelines for application review, indicating a 45-day period for standard applications and a 90-day frame when disability factors into eligibility assessments. Furthermore, it touches on asset declaration requirements for patients and their spouses, elucidating on the types of assets that must be disclosed to determine eligibility and the protection of spousal assets. In essence, the DHS 4574 form encapsulates a vital procedural element for vulnerable populations in Michigan, ensuring that the bridge to necessary health care services is both navigable and equitable.

Preview - Michigan Dhs 4574 Form

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)

 

 

Balance

 

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.

1

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.

2

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

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

1.

Patient’s Name (First, Middle, Last)

 

 

 

 

2.

Name of Nursing Facility

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3. Address of Nursing Facility

 

 

 

 

 

 

City

 

State

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

4.

Phone No. of Nursing Facility

 

5. County

 

6.

Birthdate

7. Sex

 

8. Social Security Number

 

 

 

 

 

 

 

 

 

 

 

 

9.

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?

c

c

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

c c

c c

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

 

covered in the last 3 months?

 

eligible immigration status? If Yes:

 

 

 

 

 

 

25. Has a court ordered anyone to pay your

 

a. Immigration document type ______________

 

 

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

 

 

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?

 

 

 

 

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

 

 

 

 

contract, such as a life care contract, that

 

Hawaiian or Other Paciic Islander, W = White

 

 

 

 

 

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?

 

 

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

c c

c c

c c

c c

c c

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

3

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?

c

c

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

4

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

NO

 

 

Amount

Whose Income

 

 

 

 

 

 

 

 

 

 

 

Social Security Beneits (RSDI) Claim #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Social Security Beneits (RSDI) Claim #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Supplemental Security Income (SSI)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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

 

NO

 

 

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.

5

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.

6
Click for Michigan Dhs 4574 PDF Form

Form Characteristics

Fact Name Description
Purpose of the Form This form is used for applying for health care coverage specifically for patients in nursing facilities.
Processing Timeframe Applications must be processed within 45 days, or within 90 days if disability is a factor for determining eligibility.
Non-Discrimination Policy The Michigan Department of Health and Human Services (MDHHS) does not discriminate on the basis of race, religion, age, national origin, color, height, weight, marital status, genetic information, sex, sexual orientation, gender identity or expression, political beliefs, or disability.
Legal Authority The form is governed by 42 CFR Part 435.
Completion and Penalty Completion of the form is voluntary, but not completing it may result in no healthcare coverage being provided.

Guidelines on Utilizing Michigan Dhs 4574

The process of applying for health care coverage as a patient of a nursing facility in Michigan involves filling out the Michigan DHS 4574 form. This document is essential for individuals in nursing facilities to get their health care coverage application processed. It's imperative to read each question carefully and provide accurate and complete answers to ensure the application is evaluated correctly. The information provided will be used to determine eligibility for health care coverage. Remember, assistance is available for those who need help with the application, and interpretation services are offered at no cost to applicants requiring this support.

  1. Start by providing the beneficiary's name, Client ID, and Case Number in the sections titled "FOR OFFICE USE ONLY" at the top of the form. If you do not have this information, leave it blank.
  2. Indicate whether you require an interpreter for the interview by checking 'Yes' or 'No' and specify the language if applicable.
  3. Under "PLEASE PRINT," fill in the patient's name (first, middle, last), the phone number of the nursing home, and the address of the nursing home (including number, street, rural route, city, state, zip code).
  4. Enter the patient's birthdate (month/day/year) and Social Security number.
  5. If applicable, fill in the spouse's information, including name (first, middle, last), phone number, address (if different from the patient's), birthdate, and Social Security number. Remember, providing the spouse's Social Security number is optional unless assistance is being requested for the spouse.
  6. In the "ASSETS DECLARATION" section, specify the date as of which you are providing information about you and/or your spouse's assets.
  7. Check 'Yes' or 'No' under the question asking if you and/or your spouse have any assets. If 'Yes,' proceed to check all types of assets owned and fill in the corresponding table with the required details: Type(s) of Asset(s), Name and address of bank, insurance company, etc., Account/policy number, Owner(s), and Balance of asset(s) amount or value.
  8. Ensure all information provided is accurate and up to date. Double-check the form for completeness.
  9. Review the non-discrimination statement at the end of the form to understand your rights.
  10. Sign your name on pages 2 and 4 as instructed to indicate that you have provided truthful information and agree to the terms.
  11. After completing the form, submit it by mailing or having someone take it to your local Michigan Department of Health and Human Services (MDHHS) office for processing.

Once your application has been submitted, it will be reviewed to determine your eligibility for health care coverage. The review process takes up to 45 days, or 90 days if determining eligibility involves assessing a disability. It's important to submit the application as soon as possible to avoid delays in receiving health care coverage.

Crucial Points on This Form

What is the purpose of the Michigan DHS 4574 form?

The Michigan DHS 4574 form is an application designed for individuals in nursing facilities seeking health care coverage through the Michigan Department of Health and Human Services (MDHHS). Its primary purpose is to assess applicants' eligibility for health care coverage by collecting personal information, financial details, and other relevant data. This form plays a crucial role in ensuring that eligible individuals receive the health care benefits to which they are entitled.

Who needs to fill out this form?

This form must be completed by any patient currently residing in a nursing facility who wishes to apply for health care coverage under the programs offered by the Michigan Department of Health and Human Services. If other family members require assistance with medical expenses, they should use the DCH-1426, Application for Health Coverage and Help Paying Costs, instead.

What is the time frame for the processing of this form?

After submission, the application must be processed within 45 days. However, if a disability is a factor in determining eligibility for health care coverage, the processing time extends to 90 days. These time frames ensure that the application is reviewed and a decision is made in a timely manner.

Is it mandatory to report all assets when filling out the DHS-4574 form?

Yes, it is mandatory to report all assets owned by the applicant and/or their spouse when filling out the DHS-4574 form. This includes any assets held jointly with family or other persons. The form requires detailed information about various types of assets, including but not limited to, checking and savings accounts, real estate, and life insurance policies. This information is crucial for determining the applicant's eligibility and the extent of coverage for which they qualify.

What should I do if I need help filling out the form or require an interpreter?

The Michigan Department of Health and Human Services (MDHHS) is committed to providing assistance to anyone who needs help filling out the application. If you require help or need an interpreter, you can contact your specialist or visit the local office mentioned in the form. The department will provide an interpreter free of charge, or you may choose to use one of your own. It is important to ensure that all applicants have the support they need to accurately complete their application.

Common mistakes

Filling out the Michigan DHS 4574 form, an application for health care coverage, especially for patients in nursing facilities, involves navigating through intricate details and requires attentiveness to avoid common mistakes. Here are five common mistakes people make when completing this form:

One widespread mistake is overlooking the need for complete and accurate information about each asset. It's critical to list all assets owned by you or jointly with a spouse or others as of the specified date. This includes not just obvious assets like bank accounts and real estate but also less thought-of items such as life insurance, burial trusts, or even livestock if applicable. Failure to disclose all assets can impact eligibility determinations.

Another error involves misunderstanding the question about needing an interpreter. Applicants sometimes skip this question if they are completing the form without help, not realizing that this could affect their ability to communicate effectively during the application process. The Michigan Department of Health and Human Services (MDHHS) offers free interpreter services, and indicating your language needs can ensure smoother communication.

Incorrectly marking the section with the assets declaration is also common. Applicants can mistakenly check 'No' without fully understanding that the section requires information about any asset, not just specific types they might be thinking of. It's essential to review all asset types listed on the form and provide detailed information for each one that applies to you or your spouse.

Not signing the form on pages 2 and 4 is a simple yet significant oversight. A missing signature can delay the processing of the application, as it is considered incomplete without the applicant's signature. This requirement is specifically highlighted in the instructions, urging applicants to read carefully and ensure all necessary signatures are in place.

Lastly, applicants often forget to utilize the available resources for assistance. The form explicitly states that help is available for filling out the application, including the provision of an interpreter if needed. Not reaching out for help, particularly if there are questions or uncertainties, can result in inaccuracies or incomplete information, both of which can adversely affect the application process.

Documents used along the form

When navigating the complex landscape of applying for healthcare coverage, particularly for patients in nursing facilities in Michigan, the DHS-4574 form is just the starting point. This document is a critical application for health care coverage but often needs to be complemented with other forms and documents to ensure a comprehensive application process. Understanding these additional forms can simplify the steps needed to secure healthcare coverage effectively.

  • DCH-1426 Application for Health Coverage and Help Paying Costs: If other family members require assistance with medical expenses, this application is necessary. It expands the scope of coverage beyond the individual applying through the DHS-4574 form.
  • Proof of Identity Documents: Copies of government-issued identification documents for the applicant and, if relevant, their spouse. This ensures that the application is attributed to the correct individuals.
  • Income Verification: Documents such as pay stubs, tax returns, or employer verification forms are needed to confirm the income stated in the application, which is crucial for determining eligibility and the extent of coverage.
  • Asset Verification Documents: Bank statements, property deeds, and other documents that can prove the value of assets owned. These are important for assessing eligibility, particularly for programs with asset limits.
  • Proof of Residency: Utility bills, lease agreements, or mortgage statements can serve as proof that the applicant resides in Michigan, a prerequisite for receiving state-specific health care coverage.
  • Proof of Disability: If disability is a factor in determining eligibility, documents such as a Social Security Disability Insurance (SSDI) award letter or a physician’s statement can be necessary.
  • Authorization for Release of Information: This allows the Michigan Department of Health and Human Services to verify information with other agencies or third parties, critical for processing the application.
  • Immigration Status Documentation: For non-U.S. citizens, documents like a Green Card, Visa, or naturalization papers may be required to establish eligibility for healthcare coverage.
  • Social Security Number Verification: A social security card or official document containing the Social Security number for every member of the household applying for coverage.

In the journey towards securing healthcare coverage through the Michigan Department of Health and Human Services, each of these documents plays a pivotal role alongside the DHS-4574 form. They collectively help in painting a complete picture of the applicant's eligibility and needs. It's imperative for applicants to gather and submit these forms meticulously to navigate the application process smoothly. Ensuring that every detail is accurately represented not only facilitates a quicker review but also maximizes the chances of securing the necessary healthcare coverage.

Similar forms

  • The DCH-1426 Form, Application for Health Coverage and Help Paying Costs, is similar to the Michigan DHS 4574 form as both are used for applying for health care coverage. The DCH-1426 form is particularly for individuals or families who seek assistance with medical expenses, facilitating a broader scope of applicants.

  • The SSI Application shares similarities with the DHS 4574 form, especially in the aspect of providing information relevant to determining eligibility for benefits. While the SSI application is focused on supplemental security income for aged, blind, or disabled people, both require detailed personal and financial information.

  • Medicaid Application Forms from other states are akin to the Michigan DHS 4574 form in their purpose. Each state's Medicaid application is designed to collect essential information to assess eligibility for health care benefits, though specifics vary according to state laws and requirements.

  • The SNAP (Supplemental Nutrition Assistance Program) Application is another form related to the Michigan DHS 4574, as both are government assistance programs requiring information about household composition, income, and other eligibility criteria to provide benefits.

  • The Medicare Enrollment Application has parallels with the DHS 4574 form, since both involve the process of applying for health care coverage. While Medicare is specifically for individuals who are 65 years old or older, or who meet other specific criteria, both applications gather detailed personal information to determine eligibility.

  • A Disability Benefits Application is similar to the DHS 4574 form because it involves determining eligibility for health coverage based on disability status among other factors. Both applications require comprehensive details about the applicant's medical condition, financial status, and care needs.

  • The Asset Declaration Form for Medicaid, which is specifically designed to assess the assets of individuals or couples applying for Medicaid, resembles the assets declaration section in the DHS 4574 form. Both documents are vital for understanding the financial situation of the applicant to ascertain qualification for health coverage.

  • The Health Insurance Marketplace Application is akin to the DHS 4574 form as it's a procedure for applying for health care coverage, assessing eligibility based on a range of criteria including income, household size, and more, although it's focused on obtaining insurance through the Affordable Care Act's Marketplace.

  • CHIP (Children's Health Insurance Program) Application shares a purpose with the DHS 4574 form as both are concerned with providing health care coverage, specifically for children in the case of CHIP, requiring detailed information to evaluate if applicants meet the criteria for assistance.

  • The Veterans Health Care Enrollment Application is related to the DHS 4574 form, with both aiming to enroll applicants in health care programs. However, the focus of this application is on veterans, requiring specific information about military service, health conditions related to service, and other eligibility factors.

Dos and Don'ts

When filling out the Michigan DHS 4574 form for healthcare coverage, especially as a patient of a nursing facility, it's crucial to understand correctly what you should and shouldn't do. This guidance ensures the process is smooth and increases the chances of your application being accepted. Here’s a breakdown to help you navigate the process:

Things You Should Do:

  1. Read the instructions carefully before starting to fill out the form. Paying attention to every detail can prevent errors and reduce the risk of your application being delayed or denied.

  2. Complete every section that applies to you and your spouse, if you have one. Skipping sections or questions can lead to incomplete information and affect your eligibility.

  3. Provide accurate information about your assets. Inaccuracies can not only affect your eligibility but also lead to legal consequences.

  4. Ask for assistance if you're unsure about any part of the application. Remember, help is available through the Michigan Department of Health and Human Services (MDHHS).

  5. Use an interpreter if English is not your first language. MDHHS can provide one at no cost to ensure you understand the application process.

  6. Sign and date the form on pages 2 and 4, as your signature is mandatory for the application to be processed.

Things You Shouldn't Do:

  1. Don’t leave any questions unanswered. If a question doesn't apply, indicate that with an "N/A" (not applicable) instead of leaving it blank.

  2. Avoid rough estimates when reporting your assets. It’s imperative to provide exact numbers to ensure your information is factual and accurate.

  3. Don't provide false information, intentionally or by mistake. Doing so could lead to denial of coverage and other penalties.

  4. Don’t forget to include information about all types of assets, including those jointly owned, to ensure a comprehensive declaration.

  5. Do not disregard the need for an interpreter if you’re not confident in your English proficiency. Misunderstandings can lead to errors in your application.

  6. Avoid sending the form without double-checking all the information and ensuring it’s fully completed. Mistakes or omissions can lead to processing delays.

Following these guidelines will help ensure that your application for healthcare coverage through the DHS 4574 form is complete and accurate, allowing for a smoother and more efficient review process.

Misconceptions

When people talk about the Michigan Department of Health and Human Services (MDHHS) DHS-4574 form, there are a lot of misconceptions floating around. Let's clear up some of the most common misunderstandings:

  • Only for Long-Term Stays: Some think this form is only for those planning long-term stays in nursing facilities. However, it's actually for anyone applying for health care coverage who is a patient in a nursing facility, regardless of the length of their stay.
  • Help Is Hard to Get: There's a misconception that assistance in filling out the form is difficult to obtain. In truth, the MDHHS is committed to helping all applicants fill out the form upon request, including providing interpreters if needed.
  • Interpreters Cost Extra: People often believe that asking for an interpreter will incur an extra fee. The department provides interpreters free of charge to ensure everyone has access to the help they need.
  • Discrimination Concerns: There's an unfounded worry that applicants might face discrimination based on personal attributes. The MDHHS does not discriminate on the basis of race, religion, age, national origin, gender, and several other categories.
  • Application Process Length: A common belief is that the application process is endlessly long. While it's comprehensive, there are clear timelines: 45 days for regular processing and 90 days if disability is a factor in determining eligibility.
  • Exclusivity to Patients: Some think the form is exclusive to the patient only. If the spouse of a patient needs assistance with medical expenses, they can use the DCH-1426 form for health coverage and help paying costs, which shows there are resources for family members too.
  • Voluntary Completion: Another misconception is that every section of the form must be completed for submission. While it's beneficial to provide as much information as possible, certain parts are marked as "voluntary," indicating that not filling them out does not automatically penalize the application with a denial of healthcare coverage.
  • Assets Declaration Complexity: It's commonly misunderstood that the assets declaration is overwhelmingly complicated. Though detailed, this section is crucial for determining eligibility and protecting assets for the benefit of the patient's spouse, and help is available to understand and complete it accurately.

Understanding these misconceptions can make the process of applying for health care coverage through the DHS-4574 form a bit less daunting. Remember, assistance is always available, and ensuring you're informed will help you navigate the process more smoothly.

Key takeaways

When preparing to fill out the Michigan DHS 4574 form, here are key takeaways to ensure the process is completed accurately and effectively:

  • The Michigan Department of Health and Human Services (MDHHS) is committed to assisting all individuals in filling out the application upon request. This helps to ensure that everyone has equal access to healthcare coverage applications, regardless of their familiarity with the process.
  • If you require assistance due to a language barrier, MDHHS provides interpreters at no cost. This ensures that non-English speakers or those more comfortable in another language receive the help they need in completing the form.
  • For nursing facility patients, the DHS 4574 form is specifically designed for your application for health care coverage. It's important to read each question carefully to provide accurate information that affects eligibility.
  • Applicants must sign their names on specified pages of the form as part of the completion process, ensuring that the information provided is validated by the patient or their representative.
  • The form can be submitted by mail or in person at your local MDHHS office, providing flexibility in how you choose to apply for health care coverage.
  • Applications must be processed within 45 days, or within 90 days if disability is a determining factor for eligibility. This timeline helps applicants understand when they can expect a decision.
  • For those seeking assistance with medical expenses for other family members, the DCH-1426 form is recommended. This highlights the availability of additional resources for comprehensive family healthcare coverage.
  • MDHHS practices non-discrimination in processing applications, ensuring fair treatment regardless of race, religion, age, and other factors. This commitment to equality is crucial for all applicants to understand.
  • The form outlines a section on asset declaration for the patient and, if applicable, their spouse. Completing this section accurately is vital for determining eligibility and the potential coverage benefits.

By keeping these key points in mind, applicants can navigate the process of applying for health care coverage through the Michigan DHS 4574 form with a clearer understanding and greater confidence.

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