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The Michigan DHS 4574 form, officially titled "Application for Health Care Coverage Patient of Nursing Facility," is a critical document designed for individuals residing in nursing facilities who seek health care coverage through the Michigan Department of Health and Human Services (MDHHS). This form collects essential information to assess eligibility for health care coverage, particularly focusing on the applicant's personal and financial details. It requires the beneficiary's name, client ID, case number, and contact information, as well as information about their spouse if applicable. The form emphasizes the importance of assistance in completing the application, offering support through MDHHS specialists and interpreters at no cost. Additionally, it outlines the time frame within which the application will be processed, stating that approval or denial must occur within 45 days, or 90 days if disability is a factor. The DHS 4574 also contains a section for asset declaration, where applicants must disclose their and their spouse's assets to determine eligibility and the protection of certain assets for the spouse's benefit. The form underscores MDHHS's commitment to non-discrimination and provides guidance for applicants needing help or facing challenges during the application process.

Sample - 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.

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Form Information

Fact Name Fact Description
Form Purpose The DHS 4574 form is used to apply for health care coverage specifically for patients in nursing facilities.
Assistance Availability The Michigan Department of Health and Human Services (MDHHS) offers assistance to anyone needing help with the application.
Interpreter Services MDHHS provides interpreter services at no cost if needed for the application process.
Eligibility Determination Eligibility for health care coverage is determined based on the information provided in the application.
Application Processing Time The application must be approved or denied within 45 days, or 90 days if disability is a factor.
Governing Law This form is governed by 42 CFR Part 435, which outlines federal regulations for Medicaid eligibility.
Non-Discrimination Policy MDHHS does not discriminate based on race, religion, age, or other personal characteristics.

Detailed Guide for Filling Out Michigan Dhs 4574

After completing the Michigan DHS 4574 form, you will need to submit it to your local Michigan Department of Health and Human Services (MDHHS) office. The processing time for your application will vary based on your specific circumstances. Ensure that you provide accurate information to avoid delays.

  1. Obtain the form: Download the Michigan DHS 4574 form from the MDHHS website or request a physical copy from your local office.
  2. Fill in beneficiary details: Write the beneficiary's name, client ID, case number, county, district, section, and unit specialist information at the top of the form.
  3. Indicate need for interpreter: Answer the question regarding whether you need an interpreter during the interview. If yes, specify the language.
  4. Provide patient information: Enter the patient's name, phone number, birthdate, and Social Security number.
  5. Include spouse information: If applicable, fill in the spouse's name, phone number, birthdate, and Social Security number.
  6. List nursing home details: Fill in the address of the nursing home where the patient resides, including city, state, and zip code.
  7. Declare assets: Answer the questions about assets owned by you and/or your spouse. Mark all applicable asset types and provide details in the table provided.
  8. Sign the form: Ensure that you sign your name on pages 2 and 4 as required.
  9. Submit the application: Mail the completed form or deliver it in person to your local MDHHS office.

Obtain Answers on Michigan Dhs 4574

  1. What is the Michigan DHS 4574 form?

    The Michigan DHS 4574 form is an application specifically designed for individuals residing in nursing facilities who are seeking health care coverage. It collects essential information to determine eligibility for health care benefits through the Michigan Department of Health and Human Services (MDHHS).

  2. Who should complete the DHS 4574 form?

    This form should be completed by patients who are currently in a nursing facility. If you are a patient or a representative of a patient in such a facility, it is important to fill out this application to access necessary health care coverage.

  3. How do I submit the DHS 4574 form?

    You can submit the form by mailing it to your local MDHHS office or by having someone deliver it in person. It is important to ensure that the application is sent to the correct office to avoid any delays in processing.

  4. What happens after I submit the form?

    Once you submit the DHS 4574 form, the MDHHS is required to process your application. You will receive a decision regarding your eligibility for health care coverage within:

    • 45 days for standard applications
    • 90 days if your disability status is a factor in the eligibility determination

  5. What if I need assistance filling out the form?

    If you require help completing the application, the MDHHS is obligated to assist you upon request. You can reach out to your assigned specialist or call the MDHHS for support. Additionally, if you need an interpreter, the department will provide one at no cost.

  6. What information is required on the form?

    The form requests various details, including personal information about the patient and their spouse (if applicable), contact information, and a declaration of assets. This information is crucial for determining eligibility for health care coverage.

  7. What types of assets need to be reported?

    Applicants must disclose all assets owned by themselves and/or their spouse. This includes, but is not limited to:

    • Bank accounts
    • Stocks and bonds
    • Real estate
    • Retirement accounts
    • Life insurance policies

  8. What should I do if my application is denied?

    If your application for health care coverage is denied, you have the right to appeal the decision. You can contact the MDHHS for guidance on the appeals process and to understand your options moving forward.

  9. Is there a penalty for not completing the form?

    Yes, if the DHS 4574 form is not completed or submitted, you may be ineligible for health care coverage. It is essential to complete the application accurately and submit it within the required time frame to avoid losing access to benefits.

  10. How does the MDHHS ensure non-discrimination?

    The MDHHS is committed to providing services without discrimination based on race, religion, age, national origin, and other factors. This commitment is outlined in their policies, ensuring fair treatment for all applicants.

Common mistakes

Filling out the Michigan DHS 4574 form can be a straightforward process, but mistakes can lead to delays or complications in receiving health care coverage. One common error is not providing complete and accurate information. Each section of the form requires specific details, including personal information and asset declarations. Omitting any information or making errors can result in the application being denied or delayed.

Another mistake is failing to sign the form where indicated. The application requires signatures on pages 2 and 4. Without these signatures, the application cannot be processed. It's essential to double-check that all required signatures are present before submitting the form.

Many applicants also overlook the importance of including all relevant assets. The form asks for a comprehensive list of assets owned by the applicant and their spouse. This includes bank accounts, real estate, and other financial holdings. Failing to disclose all assets can lead to issues with eligibility and may result in penalties.

Additionally, applicants sometimes forget to indicate if they require an interpreter for assistance during the application process. If language barriers exist, it is crucial to request help to ensure that the application is filled out correctly. The Michigan Department of Health and Human Services offers interpreter services free of charge.

Another frequent error is not providing the correct contact information. Applicants should ensure that their phone numbers and addresses are accurate. This information is vital for communication regarding the application status and any additional information that may be needed.

Finally, some individuals may not read the instructions carefully. The form contains important guidelines that explain how to fill it out properly. Taking the time to read these instructions can prevent many common mistakes and streamline the application process. Ensuring that each section is completed as directed will help in achieving a successful outcome.

Documents used along the form

The Michigan DHS 4574 form is an essential document for individuals seeking health care coverage while residing in a nursing facility. Alongside this form, several other documents may be required to support the application process. Each of these documents serves a specific purpose and helps ensure that applicants receive the assistance they need.

  • DCH-1426: Application for Health Coverage and Help Paying Costs - This form is used when other family members want help with medical expenses. It allows for a broader application of coverage for those who may not be in a nursing facility.
  • DHS-4574-B: Assets Declaration Patient and Spouse - This document gathers information about the assets owned by the applicant and their spouse. It is crucial for determining eligibility for health care coverage and understanding asset protection for spouses.
  • Authorization for Release of Information - This form permits the Michigan Department of Health and Human Services (MDHHS) to access necessary medical and financial information from other entities. It is vital for processing the application smoothly.
  • Verification of Income Form - This document is used to verify the applicant's income. Accurate income verification is essential to determine eligibility for various health care programs.
  • Medicaid Eligibility Verification Form - This form is specifically designed to confirm Medicaid eligibility. It helps streamline the process for applicants seeking assistance through Medicaid.
  • Proof of Residency - Applicants may need to provide documentation that confirms their residency status. This could include utility bills, lease agreements, or other official correspondence that shows the applicant's current address.

Understanding the purpose of each of these documents can significantly ease the application process for health care coverage. By gathering the necessary forms and providing accurate information, individuals can better navigate their path to receiving essential health services.

Similar forms

The Michigan DHS 4574 form, which serves as an application for health care coverage for patients in nursing facilities, shares similarities with several other important documents. Each of these forms plays a crucial role in determining eligibility for health care benefits or assistance. Here are six documents that are comparable to the DHS 4574 form:

  • DCH-1426, Application for Health Coverage and Help Paying Costs: This form is used by family members seeking assistance with medical expenses. Like the DHS 4574, it collects personal and financial information to assess eligibility for health care coverage.
  • Medicaid Application: This application is essential for individuals seeking Medicaid benefits. Similar to the DHS 4574, it requires detailed information about income, assets, and household composition to determine eligibility.
  • Long-Term Care Application: Designed for those applying for long-term care services, this form gathers information about the applicant's health status and financial situation. It parallels the DHS 4574 in its focus on health care coverage for individuals in nursing facilities.
  • Asset Declaration Form: This document is often required to disclose financial assets and resources. Like the DHS 4574, it helps determine eligibility for health care programs by assessing the applicant's financial situation.
  • Social Security Administration (SSA) Application for Benefits: This application is used to apply for Social Security benefits, including disability. It shares similarities with the DHS 4574 in that it requires personal information and documentation to evaluate eligibility for financial assistance.
  • Supplemental Security Income (SSI) Application: This form is for individuals seeking SSI benefits, which assist those with limited income and resources. Like the DHS 4574, it focuses on the applicant’s financial and personal circumstances to determine eligibility for support.

Dos and Don'ts

When filling out the Michigan DHS 4574 form, it’s important to follow some guidelines to ensure your application is processed smoothly. Here’s a list of things you should and shouldn't do:

  • Do read each question carefully before answering.
  • Do provide accurate information about your assets and personal details.
  • Do sign your name on pages 2 and 4 of the application.
  • Do ask for help if you need it, either from a specialist or an interpreter.
  • Don't leave any questions unanswered; incomplete applications can delay processing.
  • Don't submit the form without checking for errors or missing information.

Following these guidelines can help ensure that your application for health care coverage is handled efficiently.

Misconceptions

  • Misconception 1: The DHS 4574 form is only for individuals under 65 years old.

    • This form is applicable to anyone residing in a nursing facility, regardless of age. It assists in determining health care coverage eligibility for patients of all ages.

  • Misconception 2: Completing the form is mandatory for everyone.

    • While the form is essential for those seeking health care coverage, its completion is voluntary. However, not filling it out may result in no coverage.

  • Misconception 3: The form can only be submitted in person.

    • The DHS 4574 form can be submitted by mail or by having someone deliver it to your local Michigan Department of Health and Human Services office.

  • Misconception 4: Assistance in completing the form is not available.

    • The Michigan Department of Health and Human Services is required to assist individuals in filling out the application upon request. Help is readily available.

  • Misconception 5: The form does not require a signature.

    • It is crucial to sign your name on pages 2 and 4 of the form. Without a signature, the application may not be processed.

  • Misconception 6: The form is only for individuals with a spouse.

    • While the form includes sections for a spouse, it is still relevant for single individuals residing in nursing facilities. All applicants must provide their own information.

  • Misconception 7: Submitting the form guarantees approval for health care coverage.

    • Submitting the DHS 4574 form does not guarantee coverage. The information provided will be evaluated to determine eligibility.

  • Misconception 8: Only financial information about the applicant is required.

    • The form requires details about both the applicant and their spouse, including assets owned jointly. This information helps assess eligibility for coverage.

  • Misconception 9: The processing time for the application is indefinite.

    • The Michigan Department of Health and Human Services has specific time frames for processing applications—45 days, or 90 days if disability is a factor.

  • Misconception 10: The form is only available in English.

    • The DHS 4574 form is available in multiple languages, and the Department provides interpreters free of charge to assist applicants during the application process.

Key takeaways

When filling out the Michigan DHS 4574 form, keep the following key points in mind:

  • Purpose: This form is specifically for individuals in nursing facilities applying for health care coverage.
  • Assistance: The Michigan Department of Health and Human Services (MDHHS) offers help to complete the application if needed.
  • Interpreter Services: If you require an interpreter, MDHHS will provide one at no cost.
  • Eligibility Determination: The information provided will determine your eligibility for health care coverage.
  • Timelines: Your application must be processed within 45 days, or 90 days if disability is involved.
  • Signature Requirement: Ensure you sign your name on pages 2 and 4 of the form.
  • Local Office Submission: You can submit the form by mail or in person at your local MDHHS office.
  • Asset Declaration: Be prepared to provide details about your assets and those of your spouse, if applicable.
  • Non-Discrimination Policy: MDHHS does not discriminate based on various factors, including race and disability.
  • Alternative Applications: Use form DCH-1426 if other family members need assistance with medical expenses.

Completing the Michigan DHS 4574 form accurately and promptly is crucial for ensuring you receive the necessary health care coverage. Take your time to read each section carefully and seek help if needed.