DHS-3243 (Rev. 10-14) Bridges
RETROACTIVE MEDICAID APPLICATION
1.
My family has unpaid medical bills for the month(s) of:
First
Month
Year
Second
Month
Year
Third
Month
Month
Month
Month
ANSWER QUESTIONS 2-9 FOR EACH MONTH APPLIED FOR IN QUESTION 1.
2.
List yourself and the name of each family
member who lived with you at any time during
the first month or who you claim as a
dependent on your tax return. Check yes if the
person has unpaid medical expenses this
month.
2.
List yourself and the name of each family
member who lived with you at any time during
the second month or who you claim as a
dependent on your tax return. Check yes if the
person has unpaid medical expenses this
month.
2.
List yourself and the name of each family
member who lived with you at any time during
the third month or who you claim as a
dependent on your tax return. Check yes if the
person has unpaid medical expenses this
month.
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
3.
Was a family member(s) in a hospital, nursing
home, or away from home on the last day of
the first month?
YES NO
If YES, enter name of family member(s):
3.
Was a family member(s) in a hospital, nursing
home, or away from home on the last day of
the second month?
YES NO
If YES, enter name of family member(s):
3.
Was a family member(s) in a hospital, nursing
home, or away from home on the last day of
the third month?
YES NO
If YES, enter name of family member(s):
4.
Explain any changes during the first month
(child born, family member left or returned
home, married, divorced, died, began or ended
pregnancy, began or quit work) and indicate
date of change.
4.
Explain any changes during the second month
(child born, family member left or returned
home, married, divorced, died, began or ended
pregnancy, began or quit work) and indicate
date of change.
4.
Explain any changes during the third month
(child born, family member left or returned
home, married, divorced, died, began or ended
pregnancy, began or quit work) and indicate
date of change.
over
DHS-3243 (Rev. 10-14) Bridges
INCOME: For each month applied for, attach proof of all income received.
5.
Was any family member
employed or self-employed in
any of the months listed in
question 1? YES NO
If YES, complete the following:
FIRST MONTH
SECOND MONTH
THIRD MONTH
Total
monthly earned
income before
deductions.
Names of children
receiving child
care due to
employment.
Total
monthly earned
income before
deductions.
Names of children
receiving child
care due to
employment.
Total
monthly earned
income before
deductions.
Names of
children receiving
child care due to
employment.
Person employed:
$
$
$
$
$
$
Name of Self-Employed
Person
Gross Monthly income, minus allowable
federal tax deductions
(DEPRECIATION not allowed)
Gross Monthly income, minus allowable
federal tax deductions
(DEPRECIATION not allowed)
Gross Monthly income, minus allowable
federal tax deductions
(DEPRECIATION not allowed)
EXPENSES: Attach copy of court order(s) for child support paid.
6.
Did any family member pay child
support in any of the months listed
in question 1?
YES NO If
YES, complete the following:
Total monthly
child support
paid per person
Total monthly
child support
paid per person
Total monthly
child support
paid per person
Person(s) paying child support:
$
$
$
7.
Did any family member pay guard-
ianship/conservator expenses in any
of the months listed in question 1?
YES NO If YES, who pays?
Total monthly guardianship/
conservator expenses paid per
person
Total monthly guardianship/
conservator expenses paid per
person
Total monthly guardianship/
conservator expenses paid per
person
Person(s) paying guardianship/
conservator expenses:
$
$
$
8.
Does any family member pay
alimony expenses in any of the
months listed in question 1?
YES
NO If YES, who pays?
Total monthly alimony expenses
paid per person
Total monthly alimony expenses
paid per person
Total monthly alimony expenses
paid per person
Person(s) paying alimony expenses:
$
$
$
9.
Did any family member pay student
loan expenses in any of the months
listed in question 1?
YES NO
If YES, who pays?
Total monthly student loan
expenses paid per person
Total monthly student loan
expenses paid per person
Total monthly student loan
expenses paid per person
Person(s) paying student loan expenses:
$
$
$
10.
Did any family member pay other
expenses in any of the months listed
in question 1?
YES NO If YES,
who pays?
Total monthly other expenses
paid per person
Total monthly other expenses paid
per person
Total monthly other expenses
paid per person
Person(s) paying other expenses:
$
$
$
11.
OTHER INCOME: Include income of all family members. Each item must be answered YES or NO.
FIRST MONTH
Month
Year
SECOND MONTH
Month
Year
THIRD MONTH
Month
Year
INCOME TYPE YES/NO
MONTHLY
AMOUNT
WHOSE
INCOME
YES/NO
MONTHLY
AMOUNT
WHOSE
INCOME
YES/NO
MONTHLY
AMOUNT
WHOSE
INCOME
Social Security
Benefits (RSDI)
$
$
$
Supplemental
Security Income
(SSI)
$
$
$
Retirement or
Pension Benefits
$
$
$
DHS-3243 (Rev. 10-14) Bridges
Disability Benefits
$
$
$
Rental Income
$
$
$
Workers
Compensation
$
$
$
Child Support
$
$
$
Alimony
$
$
$
Unemployment
compensation
$
$
$
Military Allotments
$
$
$
Gambling
Distributions
(Casino profit
sharing)
$
$
$
Other
$
$
$
12.
ASSETS: Include assets of all family members. Each item must be answered YES or NO. Attach proof of asset value for each retro month applied for.
FIRST MONTH
Month
Year
SECOND MONTH
Month
Year
THIRD MONTH
Month
Year
ASSET TYPE YES/NO AMOUNT/VALUE OWNER(S) YES/NO AMOUNT/VALUE OWNER(S) YES/NO AMOUNT/VALUE OWNER(S)
Cash on hand, in a
safety deposit box or
patient trust fund
$
$
$
Savings, Checking or
Credit Union
Accounts
$
$
$
Home, life estate, life
lease
$
$
$
Real Estate (not your
home)
$
$
$
Mortgage, land con-
tract or other notes
payable to household
member
$
$
$
Savings bonds or
money market funds
$
$
$
Stocks or mutual
funds
$
$
$
IRA, KEOGH, 401K
or deferred
compensation
accounts
$
$
$
Trust Fund(s)
$
$
$
Life insurance
$
$
$
Annuity
$
$
$
Cars, trucks, boats,
motorcycles, other
vehicles
$
$
$
Tools & Equipment,
Livestock or Crops
$
$
$
Funeral contracts
$
$
$
Burial plot(s),
casket, etc.
$
$
$
Certificates of
Deposit (C.D.) or
savings certificates
$
$
$
Other
$
$
$
I CERTIFY THAT ALL INFORMATION I HAVE WRITTEN ON THIS FORM IS TRUE TO THE BEST OF MY KNOWLEDGE.
Signature
Date
Department of Human Services (DHS) will not discriminate against any individual or group because of race, religion, age, national origin, color, height,
weight, marital status, sex, sexual orientation, gender identity or expression, political beliefs or disability. If you need help with reading, writing, hearing, etc.,
under the Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your area.
AUTHORITY: Federal 42 CFR 435 COMPLETION: Voluntary PENALTY: No medical coverage will be authorized.