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I would like more information only at this time. (GO TO "CONTACT US")
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I would like a Medicurity advocate to contact me regarding this matter. (Complete the
Questionnaire.)
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1. Name of Elderly/Disbled Individual
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2. Your Name/Relationship to Individual
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3. Your Email Address
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4. Your Phone Number
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5. Name of Power of Attorney or Guardian?
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6. Does the individual receive home health care or
reside in a nursing facility or assisted living facility?
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7. Does the person own their own home, farm, or
business property? Appraised/Assessed Value?
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8. Does the individual own a vehicle? Fair Market
Value?
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9. Does the individual have assets/resources:
Cash
Checking/savings
CD's
Life Insurance w/Cash Value
Annuities
Irrevocable Trust
Business (Partnership/LLC's)
Stocks/Bonds
Mutual Funds/Money Market
Promissory Notes
Other real estate
Total Value of Estate (assets)?
10. Has the individual sold, transferred, loaned, or
given away assets (cash or property) in the last 5
years?
Total value of all gifts/loans
11. Does the individual have:
Family live-in Caregiver
Disabled children
Spouse at home
12. Is the individual a veteran or surviving spouse of
a veteran?
13. Total Debt owed by individual
14. Montly cost of care (out of pocket) for individual
(nursing home, home health care, prescriptions,
anciallaries/incidentals)
15. Does the individual pay health insurance
premiums? What's the monthly cost?
16. Does the individual have utitity and shelter
expenses (mortgage, rent, home owner's insurance
and property taxes)?
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10. The individual receives monthly income
from:
Social Security
Pensions
Annuities
Long-Term Care/Disability Insurance
Rental/self-employment income
VA
Other
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Briefly list immediate issues and concerns,
as well as the goal(s) of the indiviudal and
family in the space provided below:
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