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Medicaid quiz
Step
1
of
8
- Contact Information
12%
How old are you?
*
Are you married or single?
*
Married
Single
Do you have any chronic illnesses or disabilities?
*
Are you currently receiving long-term care services or do you anticipate needing them in the near future?
*
Yes, I am receiving it currently
No, and don’t anticipate
No, but anticipate in the future
What is your annual income (including pensions, Social Security, etc.)?
*
What are your total savings and investment values?
*
Do you own any real estate?
*
Yes
No
what is its approximate value?
*
Do you own any assets jointly with someone else?
*
Yes
No
Have you transferred any assets in the last five years?
*
Yes
No
Do you have any long-term care insurance policies?
*
Yes
No
Are you living in your own home, with family, or in a care facility?
*
In own home
With family
In care facility
Do you plan to stay there or sell it in the near future?
*
I plan to stay there
I plan to sell it in the near future
Do you have family members who depend on you financially?
*
Yes
No
Do you have family members who can provide care or financial support if needed?
*
Yes
No
Name
*
Phone
*
Email
*