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Medicaid Checklist

All applicants and their spouse must provide the following verifications:
  • Birth Certificate
  • Social Security Card
  • Verification of Address
  • Marriage Certificate
You must also provide verification for any of the following items that may pertain to your situation (if you are married, verifications for both husband and wife must be presented):
  • Naturalization Papers or Alien Registration Card. 
  • Medicare Card. 
  • Proof of Blue Cross/Blue Shield and/or private health insurance plus a premium bill or other proof of cost of last premium paid. 
  • Proof of residence prior to admission to a Long Term Care Facility (nursing home). 
  • Armed services discharge papers or other proof of service for applicant and spouse. 
  • If separated or divorced – proof of separation or divorce. 
  • If spouse is deceased – copy of Death Certificate. 
  • All bank and credit union account transactions for the past 60 months to date: savings, checking, Certificates of Deposit (CD), Individual Retirement Accounts (IRA). Verification must be passbook or account statements. This applies to both open and closed accounts. 
  • Explanation and proof (including receipts and cancelled checks) of all large ($2,000.00 or more) withdrawals and deposits in bank/credit union accounts. 
  • Last eight pay stubs/statements from employer. 
  • Letter from appropriate agency or photocopy of most recent check for: 
    • Social Security
    • Pension or retirement
    • Veteran’s Benefits
    • Railroad Retirement
    • Union Benefits
    • Workman’s Compensation
    • NYS Disability Insurance
    • Court ordered support payments
    • Note:  If any of the above benefits are deposited directly into a bank/credit union account, indicate most recent deposit on bank statement/book. 
  • Letter from hospital verifying ALC date and Medicare cut-off dates. 
  • Letter/bill from NH verifying paid through date. 
  • Stocks, bonds and/or securities owned by the applicant during the previous 60 months to date and any transactions made within this period. 
  • Face and cash values of all life insurance policies. 
  • Trust and annuity contract(s) showing the amount of principal and income. All transactions for the past 60 months to date. 
  • If applicant sold or transferred property within the previous 60 months, present closing statement of sale/proof of transfer. 
  • If applicant has tenant(s): tenant(s)’ statement/rent received; book showing amount of rental income; maintenance and repair costs. 
  • Current proof of mortgage/escrow, tax bills, homeowners insurance premium, water bill. 
  • Deed(s) to all property owned (real estate). 
  • If applicant’s representative or other has Power of Attorney for applicant, documentation for this. 
  • Cemetery Deed.
  • Tax returns and 1099s for the past 4 years.
Note: If unable to obtain Birth Certificate, Social Security Number, and/or Social Security Award amounts, request a TPQY form for the applicant by calling the Social Security Administration at 1-800-772-1213. The TPQY does not Verify citizenship.