• Texas Medicaid Long-Term Care Eligibility Questionnaire

    Complete this confidential intake with your details and documents to help us assess preliminary eligibility for Texas Medicaid nursing-facility care or STAR+PLUS HCBS.
  • Is someone answering on behalf of the applicant?*
  • Spouse Question
  • Immigration Question
  • Veteran Question
  • Authority Question
  • Prior-application Question
  • Applicant Date of Birth*
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Is the applicant a U.S. citizen?*
  • Marital Status*
  • Requested Texas Long-Term Care Medicaid Service*
  • Application Status*
  • Does the applicant have dementia or cognitive impairment?*
    • Financial Information — Applicant 
    • Upload a File
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    • Does the applicant have a Qualified Income Trust?
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    • Financial Information — Spouse 
    • Upload a File
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    • Does the spouse have a Qualified Income Trust?
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    • Five-Year Transfer History 
    • Transfer Date*
       - -
      2 digit month, 2 digit day, 4 digit year
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    • Legal Planning and Capacity 
    • Has the applicant or spouse had a will?*
    • Has the applicant or spouse signed a power of attorney?*
    • Has the applicant or spouse had guardianship or conservatorship?*
    • Has the applicant or spouse signed deeds or property transfers?*
    • Can the applicant sign legal documents?*
    • Upload a File
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    • Upload a File
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    • Is there a surviving spouse?*
    • Is there a child under 21?*
    • Is there a blind or disabled child?*
    • Does a qualifying homestead occupant live in the home?*
    • Is there a sibling ownership interest in the home?*
    • Are there hardship circumstances that may prevent recovery?*
    • Documents to Upload
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    • Certification: The information is complete and accurate*
    • Certification: Consent for the attorney’s office to review and contact the respondent*
    • Certification: Submission does not create an attorney-client relationship or guarantee Medicaid eligibility*
    • Date*
       - -
      2 digit month, 2 digit day, 4 digit year
    • Should be Empty: