Senior Industry Services (SIS) — Quick Medicaid Screening

Your Name

Relationship

Phone Number

Email Address

Senior’s Name

Zip Code (Central Texas)

1) Max assistance with ANY ADL? Click to Select1) Max assistance with ANY ADL? Click to SelectYesNoUnsureWhat is an ADL? Activities of Daily Living: bathing, dressing, toileting, eating, moving around, and transferring (in/out of bed or chair). Max assistance means the person needs hands-on help most of the time.

2) Cognitive diagnosis? Click to Select2) Cognitive diagnosis? Click to SelectYesNoUnsureWhat does this mean? A doctor has said there is memory loss or thinking changes (for example: Alzheimer’s, dementia, or serious confusion). If you’re not sure, choose “Unsure.”

3) Who is their health coverage with? Why we ask: Medicaid long‑term care covers room, board, and daily personal care — but not regular medical bills like doctor visits, x‑rays, wound care, or medications. We ask who manages their health coverage so we know what pays for medical needs alongside Medicaid. List the main one if there are several.

4) Monthly income (before deductions) Income screen: We use $2,904/month as a quick check for Texas nursing‑home Medicaid. If higher, you may still qualify with a Miller Trust. If unsure, estimate.

Countable assets totalAssets screen: We use $2,000 as a quick check. Not counted: primary home, one vehicle, personal items. Counted: cash, savings, investments. If unsure, estimate.

5) Medical POA nameWhat is Medical POA? The person legally named to make healthcare decisions if the senior can’t.

Financial POA name What is Financial POA? The person legally named to help sign and handle money paperwork.

Other insurance details

Notes

ConsentConsentBy checking, you consent to be contacted about your case. You also understand that this is for Central Texas families, and this is a Free pre-check (not a formal determination). Do not enter SSNs or account numbers.