Lawberg — Medicaid & Long-Term Care Planning Intake

Important intake notice This form is for preliminary planning only. Do not submit Social Security numbers, full account numbers, passwords, login credentials, or medical record numbers. Submitting this form does not create an attorney-client relationship unless a written engagement agreement is signed.

Before you begin

Use approximate values if exact figures are not available. The goal is to identify the major planning buckets: income, countable resources, exempt assets, real estate, spouse protection, transfer issues, estate recovery exposure, and possible real-estate-based planning.

Document uploads are intentionally not collected through this form. A secure upload method can be provided later.

Do not fill this out:

1. Person Completing This Form

Your full name

Relationship to applicant

Phone

Best way to contact you

Are you authorized to discuss the applicant’s financial/medical information?

2. Applicant Information

Applicant full legal name

Applicant date of birth

Applicant gender

Is the applicant disabled?

Is the applicant a veteran?

Is the applicant a U.S. citizen?

Applicant direct phone number

Applicant street address

ZIP code

County and state of residence

Current living situation

Facility Details

Facility name

Facility phone

Date applicant entered facility

Expected to remain in long-term care?

3. Planning Urgency

Medicaid status

When is Medicaid needed?

If filed, application date

Current monthly cost of care

Estimated private-pay months remaining

Any Medicaid notice, denial, or deadline pending?

Main reason for seeking help

4. Marital Status and Spouse Information

Applicant marital status

Is spouse also applying for Medicaid?

Spouse Details

Spouse full legal name

Spouse date of birth

Spouse gender

Spouse living situation

Does spouse have health or care needs?

Does spouse depend on applicant’s income/assets for support?

5. Monthly Gross Income

Enter gross monthly amounts before deductions. Estimates are fine.

Applicant Social Security

Applicant pension

Applicant VA benefits

Applicant retirement distributions

Applicant rental income

Applicant other income

Spouse Social Security

Spouse pension

Spouse other income

Income notes

6. Assets and Accounts

Date of institutionalization or Medicaid application

This is the date used to calculate the Community Spouse Resource Allowance (CSRA) snapshot. Asset values below should reflect balances as of this date where possible. If not yet institutionalized, leave blank and use current values.

Do not list full account numbers. Identify institution, owner, account type, and approximate value.

Checking, savings, money market, CDs, cash

Brokerage / investment accounts

Retirement accounts

Annuities

Life insurance

Vehicles and valuable personal property

Any accounts jointly owned with children or others?

Any accounts closed in last 5 years?

7. Real Estate

Does applicant own a home/homestead?

Does applicant intend to return home, even if unlikely?

Primary Residence

Home address

Approximate fair market value

Mortgage / HELOC balance

How is title held?

Who lives in the home?

Home notes

Other Real Estate

Rental property, land, timeshare, commercial property, LLC/property entity, or fractional interest

8. Family, Dependents, and Possible Transfer Exceptions

List children and key family members

Applicant has child under 21?

Applicant has blind or disabled child of any age?

Adult child lived in home and provided care for 2+ years before facility admission?

Sibling lives in home and has ownership interest?

Family notes

Caregiver Information — Personal Services Contract

If a family member has been providing care to the applicant, this information is needed to evaluate a personal services contract as a planning tool.

Has a family member been providing care to the applicant?

Caregiver name and relationship to applicant

How long has the caregiver been providing care?

Approximate hours of care provided per day

Describe the care and services provided

Has the caregiver been compensated for this care?

9. Transfers Within the Last 5 Years

Any gifts, transfers, title changes, large withdrawals, loans, or asset sales in last 5 years?

Charitable gifts in last 5 years?

Transfer Details

Please complete a separate row for each transfer. This information is used to calculate any potential transfer penalty period.

Date of transfer

Amount or value transferred

What was transferred?

Recipient name

Relationship to applicant

Date of transfer

Amount or value transferred

What was transferred?

Recipient name

Relationship to applicant

Any additional transfers or context

10. Debts and Ongoing Expenses

List debts

Ongoing expenses paid from applicant funds

13. Final Confirmation

I understand that I should not submit Social Security numbers, full account numbers, passwords, login credentials, or medical record numbers through this form.

I understand that submitting this form does not create an attorney-client relationship unless a written engagement agreement is signed.

I certify that the information provided is accurate to the best of my knowledge.

Electronic signature

Date

After submission, you may be contacted for documents through a separate secure upload process.