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The Maryland DHR form is a Long-Term Care/Waiver Medical Assistance Application used to determine eligibility for medical assistance programs in Maryland. This form requires applicants to provide various personal and financial documents to support their application. To ensure a smooth application process, it is essential to complete the form accurately and submit all required documentation.

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Dos and Don'ts

When filling out the Maryland DHR form, consider the following:

Send copies of all required documents; do not send originals.
Apply as soon as possible, even if you do not have all the documents ready.
Provide detailed information about any assets transferred in the past five years.
Ensure that you answer every question completely on the application.

Avoid these common mistakes:

Do not leave any questions unanswered; this can delay processing.
Avoid sending incomplete or outdated documents.
Do not wait until you have every document before applying.
Do not forget to include additional sheets if you need more space for answers.

Misconceptions

Understanding the Maryland DHR form can be challenging due to various misconceptions. Here are eight common misunderstandings about the Long-Term Care/Waiver Medical Assistance Application:

Misconception 1: You must have all documents ready before applying.

Many believe they need every document listed before submitting their application. In reality, it’s better to apply as soon as possible with whatever documents you have. Additional documents can be submitted later.

Misconception 2: You can only apply if you are currently receiving assistance.

This is not true. You can apply for Long-Term Care Medical Assistance even if you are not currently receiving any benefits.

Misconception 3: Original documents are required for submission.

Applicants often think they must submit original documents. However, copies are sufficient, and it is advisable to keep the originals for your records.

Misconception 4: The application process is quick and straightforward.

While the form may seem simple, the process can take time. It’s essential to be patient and provide all requested information accurately to avoid delays.

Misconception 5: You cannot apply if you have assets.

Some people think that having assets automatically disqualifies them from assistance. In fact, there are specific guidelines regarding asset limits, and many individuals can still qualify.

Misconception 6: Only seniors can apply for Long-Term Care assistance.

This is a common belief, but individuals of all ages with qualifying medical needs may apply for Long-Term Care Medical Assistance.

Misconception 7: You need a lawyer to help with the application.

While legal assistance can be beneficial, it is not a requirement to complete the application. Many individuals successfully navigate the process on their own.

Misconception 8: You will be denied if you have received assistance in the past.

Previous assistance does not automatically disqualify you from receiving Long-Term Care Medical Assistance. Each application is evaluated based on current circumstances.

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Key takeaways

Filling out the Maryland DHR form can seem daunting, but understanding the process can make it much easier. Here are some key takeaways to help you navigate this important application:

Gather Required Documents Early: Before starting the application, collect all necessary documents. This includes tax returns, bank statements, and proof of income. Having these ready will streamline the process.
Send Copies, Not Originals: When submitting your application, always send copies of your documents. Originals should be kept safe at home.
Don’t Delay Your Application: If you lack some documents, submit your application with what you have. It’s crucial to apply as soon as possible, as you can provide additional documents later.
Complete Every Section: Ensure that you answer all questions on the application thoroughly. If you need more space, feel free to attach additional sheets. Incomplete applications can lead to delays.
Understand Asset Disclosure: If you or your spouse have transferred any assets in the past five years, be prepared to disclose details about these transactions. This includes the type of asset, its value, and the recipient.

By following these takeaways, you can approach the Maryland DHR form with confidence, making the application process smoother and more efficient.

Guidelines on Utilizing Maryland Dhr

Completing the Maryland DHR form is a crucial step in applying for Long-Term Care or Waiver Medical Assistance. Gather all necessary documents before you start, as this will streamline the process. Follow these steps carefully to ensure your application is filled out correctly.

Gather required documents, including proof of income, tax returns, and financial statements. Ensure you have copies, not originals.
Begin filling out the application by entering the date signed and ensuring it is date-stamped upon receipt.
In Section A, select the benefits you are applying for, such as Long-Term Care Waiver. Indicate if you need medical assistance for past medical bills.
Provide details about any other assistance you currently receive, including your Medical Assistance ID number.
In Section B, fill in your personal information, including your last name, first name, middle name, and social security number.
Indicate your date of birth, gender, and ethnicity if you choose to provide it.
Confirm your residency status in Maryland and your marital status.
Answer whether you receive Medical Assistance from another state and if you are a U.S. citizen. If not, complete Section C regarding immigration status.
In Section D, provide your current address or the address of your long-term care facility, including the name of the facility and your entry date.
Complete Section E by listing your previous addresses for the past five years, indicating if you or your spouse owned each home.
In Section F, if you have an authorized representative, provide their details, including their name and address.
Review the application for accuracy and completeness. Attach any additional sheets if necessary.
Submit the application along with all required documents to the appropriate local department.

Form Preview Example

MARYLAND DEPARTMENT of HUMAN RESOURCES

MARYLAND DEPARTMENT of HEALTH and MENTAL HYGIENE

LONG-TERM CARE/WAIVER MEDICAL ASSISTANCE APPLICATION

Check List of Items Needed for Your Long-Term Care / Waiver Application

(Please keep this page for your records)

SEND PROOF If you do not already receive Long-Term Care Medical Assistance, we need the items listed below to process your application. Please send as many items as you can with this application. Please send copies, do not send originals. In some cases, we may need to request additional documents not listed below. If so, we will give you time to supply the additional documents.

DO NOT WAIT TO APPLY

If you do not have copies of all the documents listed, send in all the copies you do have when you apply. It is important to apply as soon as possible. We will give you more time to send additional documents needed.

If you or your spouse sold, traded, gifted, or disposed of any property, motor vehicles, stocks, bonds, cash or other assets in the past 5 years you will have to provide the following:

□ Type of asset	□ Reason for transfer
□ Value of asset	□ Who received the asset
□ Amount received for the asset

If you want to find out if your spouse can keep some of your monthly income, please provide:

□ Spouse’s gross monthly income	□ Property tax bill
□ Condo fees	□ Rent
□ Mortgage	□ Electric bill
□ Lot Rent

The following items are needed from you and your spouse to determine if you are eligible for Long-Term Care Medical Assistance:

□Federal Tax Returns for the current year and the preceding four years (please include all forms and schedules). A Record of Account can be obtained from the IRS free of charge by calling 1-800-908-9946 if your Federal tax returns cannot be located.

□Bank and Financial statements on all accounts owned and co-owned:

□Current Month (month of application)

□Previous Month (month prior to application)

□The last five years of the anniversary month of the application

□Current statement of retirement accounts

□Current statement of IRA or Keogh Accounts

□Current statements of:

□Stocks

□Bonds

□Money Market Funds

□Mutual Funds, Treasury, or Other Notes

□Certificates

□Current gross monthly income from all sources including:

□VA Pensions

□Railroad Retirement

□Pensions

□Annuities

□Face and cash value of Life Insurance policies (current annual statement)

□Current statement for burial accounts

□Burial Plot Deeds

□Life Estate Deeds

□Promissory Notes

□Mortgage Notes and Mortgage Deeds

□Trusts (including appendices, schedules, annual accountings, and amendments for the past five years)

□Private Health Insurance Cards including Medicare (copy of both sides)

□Health Insurance premium amounts

□Power of Attorney or Legal Guardianship Documents (if any)

Please continue by completely answering every question on the attached application. If you need more space to complete the application, please attach additional sheets.

DHR/FIA 9709 (REVISED 7-1-11)

Blank Page

DHR/FIA 9709 (REVISED 7-1-11)

MARYLAND DEPARTMENT OF HUMAN RESOURCES MARYLAND

DEPARTMENT OF HEALTH AND MENTAL HYGIENE LONG-TERM

CARE/WAIVER MEDICAL ASSISTANCE APPLICATION

Date Signed Application

Received in Local Department

MUST BE DATE STAMPED

FOR WORKER

USE ONLY

This part is for our

staff. Please continue

to Section A.

LDSS Office	Programs Applied For or		Assistance Unit IDs
	Receiving		Client ID

Worker’s Name

Application Date

Program Medical Coverage Group		AU ID

SECTION A – BENEFIT SELECTION: Please tell us about which benefits you want and which benefits you already have.

I am applying for:

Long-Term Care Waiver

Do you need Medical Assistance for medical bills incurred in the past 3 months?

If yes, you will need to provide copies of the bills to your case manager.

YES NO

Tell us if you are currently receiving other assistance.

Icurrently receive:

Medical Assistance ID #

If you already receive Medical Assistance, please provide your ID number.

Cash Assistance

Food Stamps

Other, list:

If you receive any other benefits, please list all the benefits here.

SECTION B – APPLICANT INFORMATION: Please tell us about yourself.

Last Name

First Name

Middle Name

Suffix

Maiden Name or Other Name

(Jr., Sr., etc.)

Social Security Number:

Additional Social Security Number:

If you have a Social Security Number, enter it here.

If you have an additional Social Security Number, enter it here.

Date of Birth: (Month,Day,Year)

Gender:

Male

Female

DHR/FIA 9709 (REVISED 7-1-11)

Page 1 of 17

SECTION B – APPLICANT INFORMATION (continued)

Ethnicity

Optional

	Race	1 – American Indian/Alaskan Native
1 – Hispanic or Latino	Optional –	2 – Asian
	Please choose	3 – Black/African American
	all race codes	3 – Black/African American
2 – Not Hispanic or Latino	all race codes	4 – Native Hawaiian/Pacific Islander
2 – Not Hispanic or Latino	that apply to you.	4 – Native Hawaiian/Pacific Islander
	that apply to you.	5 – White
		5 – White

You do not have to give information about your race or ethnicity. If you do, it will help show how we obey the Federal Civil Rights Law. We will not use this information to decide if you are eligible. If you do not give us your race, it will not affect your application. The case manager will enter a race code for statistical purposes only. Title VI of the Civil Rights Act of 1964 allows us to ask for this information.

Are you a resident of Maryland?

YES

Marital Status

Single

Married

Divorced

Separated

Widowed

Are you receiving Medical Assistance (Medicaid) benefits from another state?

YES

NO	If yes, please list the state:

Are you a U.S. Citizen?

YES NO

If you answered NO, please complete SECTION C – IMMIGRATION STATUS, below.

What is your primary language?

Do you need an interpreter?

YES

If you are not registered to vote,

would you like to receive a voter registration form?

YES

Already registered to vote

SECTION C – IMMIGRATION STATUS (FOR NON-CITIZENS ONLY)

SEND PROOF Please send a photocopy of the front and back of your INS card.

What is your current INS

On what date did you receive

Are you a Sponsored

What is your Country of

Status?

your INS Status?

Immigrant?

Origin?

_/_

YES

When did you enter the U.S.?

What is your INS Number?

If you are a refugee, please list your Refugee Resettlement

Agency:

DHR/FIA 9709 (REVISED 7-1-11)

Page 2 of 17

SECTION D – CURRENT ADDRESS of HOME or INSTITUTION/LONG-TERM CARE

FACILITY: Please tell us about your Long-Term Care Facility, if you live in one.

If you live in a facility, what is the name of the facility?

On what date did you enter the facility?

_/ _/

What is your home address or the address of your facility?

Street

City	_ State		_ ZIP

Telephone #		Cellular Telephone #

Is this your mailing address? YES NO If you checked NO, please provide your mailing address information in Section V.

Do you (applicant/recipient) intend to return home?

YES

Do you (applicant/recipient) intend to return home within 6 months?

YES

SECTION E – PREVIOUS ADDRESSES: Please tell us where you have lived for the past

	five years.
Street		Did you or your spouse own
		this home?

City		State	_ ZIP

YES

Street			Did you or your spouse own
			this home?
City	State	_ ZIP	YES	NO

Street			Did you or your spouse own
			this home?
City	State	_ ZIP	YES	NO

Street			Did you or your spouse own
			this home?
City	State	_ ZIP	YES	NO

SECTION F – AUTHORIZED REPRESENTATIVE: Do you authorize someone to represent you in this application? If so, please tell us about your authorized representative.

First Name

Middle Name

Last Name

Suffix

(Jr., Sr., III, etc.)


Address		_
City	State	_ZIP

DHR/FIA 9709 (REVISED 7-1-11)			Page 3 of 17

SECTION F – AUTHORIZED REPRESENTATIVE (continued)

Home Telephone #

Cellular Telephone #		_
Work Telephone #			_

What is the authorized representative’s relationship to you?

If answer is spouse, please complete the next question:

Do you or your spouse own this home?

YES NO

If Authorized Representative is your spouse, please provide spouse’s Social Security Number:

SECTION G – SPOUSAL INFORMATION: Please tell us about your spouse. Leave this section blank if your spouse is listed as your Authorized Representative in Section F.

Last Name

First Name

Middle Name

Suffix

Maiden Name or Other Name

(Jr., Sr., etc.)

Spouse’s Social Security Number

Street

Do you or your spouse own

this home?

City

State

_ ZIP

YES NO

Telephone #

SECTION H – DISABILITY: Please tell us about your disability, if you have one.

Are you disabled?

If yes, when did the disability begin?

YES

What is your disability?

				Premium Amount
Do you receive Medicare Part A?	YES	NO	$
Do you receive Medicare Part B?	YES	NO	$
Do you receive Medicare Part B?	YES	NO	$		SEND PROOF	Please send
					verification of the premium
Do you receive Medicare Part C?	YES	NO	$		amounts you pay
Do you receive Medicare Part D?	YES	NO	$
If yes, please provide your Medicare Claim Number:

DHR/FIA 9709 (REVISED 7-1-11)

Page 4 of 17

SECTION I – VETERAN INFORMATION: If you are a veteran, a disabled widow(er), or a disabled child of a deceased veteran, fill in this section:

SEND PROOF Please send a photocopy of the front and back of your military service card.

Veteran’s Name

Relationship to Veteran

Veteran’s Status

Military Service Number

SECTION J – MEDICAL INSURANCE: If the applicant/recipient is insured, fill in this section: If you have more than one policy, place additional information in Section V.

SEND PROOF Please send a photocopy of the front and back of your insurance card(s) and verification of the premium amounts you pay.

Policy Number

Group Number

Policy Holder Name

Relationship to Policy Holder

Policy Effective Dates

From:

To:

Policy Holder Address

Street

City

State

ZIP

Telephone

Insurance Company

Insurance Company Name

Street

City

State

ZIP

Telephone

Union

Union Local

Union Name

Number

Street

City

State

ZIP

Telephone

DHR/FIA 9709 (REVISED 7-1-11)

Page 5 of 17

SECTION K – INCOME FROM WORKING: Please tell us about any income you or your spouse are currently receiving from working, including any sick leave payments.

SEND PROOF Please send copies of any proof of pay, such as a paystub. If you need additional space to complete this section, please use Section V or attach additional sheets.

Employer Name

Type of Job

Employer Address

City

State_

ZIP

Telephone #

Date Job

Gross Wages per Pay Period, including tips and

Began_

Ended_

commissions.

per

Hours per Pay Period

How often do you get

If the job has ended, what is your last expected pay date?

paid?

Weekly

Biweekly

Monthly

SECTION L – YOUR BENEFITS AND OTHER INCOME: Please tell us about any income or benefits that you are receiving, have applied for, or have been denied.

SEND PROOF Please send current copies of statements that verify the gross amount of income you receive.

TYPE OF BENEFIT	RECEIVING INCOME			AMOUNT	APPLICATION		APPLICATION DATE OR
OR INCOME	OR BENEFITS?			AMOUNT		STATUS	DENIAL DATE
OR INCOME	OR BENEFITS?					STATUS	DENIAL DATE
Social Security
Please write your claim number:	YES	NO	$			Applied for
	YES	NO	$			Denied
						Denied

Black Lung Benefits	YES	NO	$			Applied for
Black Lung Benefits	YES	NO	$			Denied
						Denied
SSI (Supplemental Security
Income)						Applied for
Please write your claim number:	YES	NO	$			Applied for
Please write your claim number:	YES	NO	$			Denied
						Denied

Veteran’s Pension/Benefits	YES	NO	$			Applied for
Veteran’s Pension/Benefits	YES	NO	$			Denied
						Denied
Pension or Retirement	YES	NO	$			Applied for
Pension or Retirement	YES	NO	$			Denied
						Denied
Civil Service Annuity	YES	NO	$			Applied for
Civil Service Annuity	YES	NO	$			Denied
						Denied
Railroad Retirement Benefits
Please write your claim number:	YES	NO	$			Applied for
	YES	NO	$			Denied
						Denied

Alimony	YES	NO	$			Applied for
Alimony	YES	NO	$			Denied
						Denied
DHR/FIA 9709 (REVISED 7-1-11)							Page 6 of 17

SECTION L – YOUR BENEFITS AND OTHER INCOME (continued)


TYPE OF BENEFIT	RECEIVING INCOME			AMOUNT	APPLICATION	APPLICATION DATE OR
OR INCOME	OR BENEFITS?			AMOUNT	STATUS	DENIAL DATE
OR INCOME	OR BENEFITS?				STATUS	DENIAL DATE
Worker’s Compensation	YES	NO	$		Applied for
Worker’s Compensation	YES	NO	$		Denied
					Denied
Disability/Sick Benefits	YES	NO	$		Applied for
Disability/Sick Benefits	YES	NO	$		Denied
					Denied
Union Benefits	YES	NO	$		Applied for
Union Benefits	YES	NO	$		Denied
					Denied
Unemployment Benefits	YES	NO	$		Applied for
Unemployment Benefits	YES	NO	$		Denied
					Denied
Lump Sum Cash Amounts	YES	NO	$		Applied for
Lump Sum Cash Amounts	YES	NO	$		Denied
					Denied
Interest/Dividends from Stocks,					Applied for
Bonds, Savings, or other	YES	NO	$		Applied for
Bonds, Savings, or other	YES	NO	$		Denied
investments					Denied
investments
Business Income	YES	NO	$		Applied for
Business Income	YES	NO	$		Denied
					Denied
Other (e.g., Rental Income, or					Applied for
Compensation from a Legal	YES	NO	$		Applied for
Compensation from a Legal	YES	NO	$		Denied
Settlement)					Denied
Settlement)
Other					Applied for
Please describe:	YES	NO	$		Applied for
Please describe:	YES	NO	$		Denied
					Denied

SECTION M – ASSETS: Please tell us about your assets as of the first day of this month. Check YES or NO for each ASSET TYPE. If you check YES, fill in the other boxes. List all assets owned by you or your spouse individually, jointly, or with other persons. If you have more than one asset of the same type, use the “Other” boxes at the bottom of the list.

SEND PROOF Please send copies of current statements that verify the value of the assets.

ASSET TYPE	CHECK ONE	OWNER	AMOUNT	ACCOUNT NUMBER	INSTITUTION NAME

Cash on Hand	YES		$
Cash on Hand	NO		$
	NO

Checking Account	YES		$
Checking Account	NO		$
	NO

Savings Account	YES		$
Savings Account	NO		$
	NO

Credit Union Account	YES		$
Credit Union Account	NO		$
	NO

Trust Fund	YES		$
Trust Fund	NO		$
	NO

IRA or Keogh	YES		$
Account	NO		$
Account	NO

Other Retirement	YES		$
Accounts	NO		$
Accounts	NO

Stocks and Bonds	YES		$
Stocks and Bonds	NO		$
	NO

DHR/FIA 9709 (REVISED 7-1-11)					Page 7 of 17

SECTION M – ASSETS (continued)

	ASSET TYPE	CHECK ONE	OWNER	AMOUNT	ACCOUNT NUMBER	INSTITUTION NAME

Treasury or Other		YES		$
Notes		NO		$
Notes		NO

Annuity		YES		$
Annuity		NO		$
		NO

Ownership in a		YES		$
Company		NO		$
Company		NO

Patient Fund Account		YES		$
Patient Fund Account		NO		$
		NO

Other		YES		$
		NO		$
		NO

Other		YES		$
		NO		$
		NO

Other		YES		$
		NO		$
		NO

Other		YES		$
		NO		$
		NO

SECTION N – OTHER ASSETS: Please tell us about any other assets you own and assets jointly owned with other individuals. This could include livestock, recreational vehicles, or any other property of value such as collections of antiques, coins, jewelry, or stamps.

SEND PROOF Please send copies of current statements or documents that establish the fair market value of the asset(s) as well as the amount owed.

ASSET TYPE

CURRENT FAIR MARKET VALUE

CURRENT AMOUNT OWED

OWNER(S)

SECTION O – POTENTIAL ASSET OR INCOME: Please tell us about any accident settlement, trust fund, inheritance, or any other money, property, real property, or assistance you expect to receive.

SEND PROOF Please send copies of current statements or documents that describe the nature, amount, and payment schedule of the asset.

Asset Type

Lawyer Name

DHR/FIA 9709 (REVISED 7-1-11)

Page 8 of 17

Common mistakes

Incomplete Documentation: Many applicants fail to provide all required documents. Ensure you include copies of tax returns, bank statements, and proof of income. Missing documents can delay your application.
Incorrect Information: Providing inaccurate details, such as Social Security numbers or income amounts, can lead to complications. Double-check all entries for accuracy before submission.
Neglecting to Report Asset Transfers: If you or your spouse have transferred assets in the past five years, you must disclose this information. Failing to do so can result in penalties or denial of assistance.
Not Applying Promptly: Delaying your application can have serious consequences. Apply as soon as possible, even if you don't have all documents. The sooner you apply, the sooner you can receive assistance.

Free Maryland Dhr PDF

Learn More on This Form

What is the Maryland DHR form?

The Maryland DHR form is an application for Long-Term Care or Waiver Medical Assistance. It is used to determine eligibility for individuals seeking financial support for long-term care services. The form requires detailed information about your financial situation, medical needs, and personal background.

What documents do I need to submit with my application?

When applying, you should include copies of various documents. These may include federal tax returns for the past five years, bank statements, proof of income, and details about any assets you or your spouse have. If you have sold or transferred any assets in the last five years, you’ll need to provide information about those transactions as well. Always remember to send copies, not originals.

Can I apply for assistance if I don’t have all the required documents?

Yes, you can still apply even if you don’t have all the documents. It’s crucial to submit your application as soon as possible. You can provide the documents you do have, and the department will give you time to submit any additional information later.

How can I find out if my spouse can keep some of my income?

To determine if your spouse can retain some of your monthly income, you need to provide specific information. This includes your spouse’s gross monthly income and details about any housing-related expenses, like property taxes, rent, or mortgage payments. This information will help assess your financial situation accurately.

What if I need more space to complete the application?

If you require additional space to answer the questions on the application, feel free to attach extra sheets. Make sure to label them clearly so that they can be matched with your application easily.

How will I know if my application has been received?