• 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 the cost of the 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 the spouse is deceased – a copy of the 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 canceled checks) of all large ($2,000.00 or more) withdrawals and deposits in bank/credit union accounts. 
      • Last eight pay stubs/statements from the employer. 
      • Letter from the appropriate agency or photocopy 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 the most recent deposit on the 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 the applicant has tenant(s): tenant(s)’ statement/rent received; book showing the 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 the applicant’s representative or other has Power of Attorney for the 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.