Helping Oregon Seniors Protect Their Financial Dignity

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TOLL FREE
888-870-5467
The Oregon
Medicaid Experts




"From you I learned that my father qualified for a special exemption and was entitled to transfer his home to me and still immediately qualify for Medicaid. In three trips to the Medicaid office I had never been told this, and, in fact,was warned that if he gave his home away he would be disqualified for over four years. Without your advice I would never have known."



CAN I QUALIFY?

Take 3 minutes to complete form and find out!

Even if you have been told that you or your loved one doesn't qualify, or that a large spend down must be completed, we can help. Fill in and submit the following form. We will analyze your situation, free of charge, and provide you with specific (and actionable) recommendations designed to save you or your family thousands of dollars.

And of course, any information you provide is strictly confidential.
Fields under red headings are required.


Patient is Currently in:

Nursing Home Facility
Assisted Living Facility
Adult Foster Care Facility
Residential Care Facility
Memory Care Facility
In-Home Care
Provided by Spouse
Other (explain in comments)

Patient is Expected to Enter:

Nursing Home Facility
Assisted Living Facility
Adult Foster Care Facility
Residential Care Facility
Memory Care Facility
In-Home Care
Other (explain in comments)

Contact Information:

Your Name: (And Relationship to Patient)

Address, City, State, Zip:

Your Phone:

Your Email:

Best Time to Call?


Patient Information:

Patient's Marital Status:
      Single      Married      Divorced      Widowed      Patient's Gender:
      Male      Female     
Patient's Age:

Patient's Service:
      Veteran      Widow(er) of Veteran      None     
City Where Patient Resides:

Spouse Information:

Spouse's Age:


Additional Information:

Complete the questions for the Patient (plus Spouse if married) applying for Medicaid coverage in Oregon.

Monthly Income From All Sources
(estimate if necessary)

Social Security Income
Retirement/Pension Income
Annunity Income
Other Income

Patient




Spouse
 






Has the Patient or Spouse gifted any assets in the last 5 years?

Yes      No      —>  If Yes, How much? 




The Financial Aid Center
119 NW 'E' St.
Grants Pass, OR 97526

(541) 479-2415 / 888-870-5467
Fax (541) 955-7217