Medicaid Planning Questionnaire
The financial picture Medicaid will ask for, gathered once.
For a family facing nursing home or long-term care costs. Covers assets, income, expenses and the five-year look-back so we can tell you where you actually stand.
Time needed
About 90 minutes
This form is available in English and Spanish. Use the language switch at the top of the page.
Have these in front of you
- Five years of bank and brokerage statements, if you can find them
- Social Security and pension award letters
- Life insurance policies and annuity contracts
- The deed to the home
- Recent bills for care, medication and supplies
About your privacy
We do not ask for Social Security numbers or full account numbers here. Medicaid will need them later, and we will collect them with you directly. The last four digits are enough for this form.
The printed and downloadable versions are the firm's complete forms and do ask for those numbers, because the court and the agencies need them. Write them on the paper copy and bring it with you, or call the office. Please do not send those numbers through this website or by email.
How would you like to do this?
All three end up in the same place. Pick whichever suits you; there is no wrong one, and you can switch at any point.
Fill it out online
Guided, one section at a time, with plain-language help on the hard questions. It saves as you go, so you can stop and come back.
Download, fill it in, send it back
A PDF you can type into on your own computer and save. When you are done, send it back through the upload box below.
Download the fillable PDFPrint it blank
Prefer pen and paper? Print it, write your answers, and bring it to your consultation or scan it back to us.
Open the print versionSend back a completed form
Finished the PDF on your own computer? Send it here. This upload is encrypted and goes straight to the firm, which is why we ask you to use it instead of email.
If you filled in Social Security or account numbers, those are not copied out of the file. The office will ask you for them directly, so you do not need to send them any other way.
Ready to protect your family's future?
The 30-minute phone consultation is free. Answer a few quick questions and we'll match you with the right attorney for your situation. Bilingual. No obligation.
