Long Term Care Assessment

Long Term Care Assessment
Name of the person seeking the benefit (the Claimant).

First NameLast Name
In which state will the Claimant be seeking benefits or aid?
What is this persons age?
Name of the person assisting with the benefit.

First NameLast Name
Contact Number

Area CodePhone Number
Email Address
example@example.com
The person applying for the benefit is

65 or olderThe VeteranThe Surviving Spouse of a VeteranNon-Veteran
If a Veteran please share when the Veteran served. *
Does the claimant require mechanical assistance or the assistance of another person for any of the following activities?

Mobility (uses a walker or cane)Toileting (uses adult diapers or support bars or special toilet seat)Transferring (pulling up on a walker or other support to get out of bed or a chair)Bathing (use a shower chair or grab bars for bathing and showering)Dressing (needs assistance dressing from head to foot)Eating (needs assistance getting food from plate to mouth)
Has the claimant been diagnosed with any of the following?

Alzheimer'sDementiaParkinson'sLegally Blind
What is the claimant's current living situation?

Living in an assisted living community.Living at home with a Home Care Agency providing care.Living at home with friends or family providing help.Living at home with no care being provided.
What is the claimant's monthly household income?
What is the estimated cost of the community or home care monthly?
Does the claimant own a house?

Yes and planning to keep it.Yes and planning to sell it.No.Yes and not sure.
Different benefits have different asset limits. Please check the box below that best represents the assets in checking, savings, and investments only, NOT including a house, car, or personal property.

Below $50,000$50,001 to $100,000$100,001 to $150,000$150,001 to $200,000$200,001 or more
What is the name of the person and or community that gave you our information?
Should be Empty: