Effective Date: 3/2012


Word: H0055.doc

PDF: H0055.pdf



Updated: 3/2012


To request information about a person's Long-Term Care Partnership (LTCP) policy.


When to Prepare

Staff send Form H0055 to the insurance company to get pertinent information about an LTCP policy policy.

Number of Copies

Staff complete an original, typed or legibly handwritten. Staff prepares a copy of Form H0055 for the case record.


Staff send the original to the appropriate insurance company and keeps a copy in the case record. Attach Form H0003, Authorization to Furnish Information (signed by the applicant, recipient or the Responsible Person), to the original.

Form Retention

If a copy is made for the case record, keep the copy for three years.


Inside Address — Enter name and address of insurance company.

Date — Self-explanatory.

Eligibility Specialist — Self-explanatory.

Office Address, Area Code and Telephone No. — Self-explanatory.

Name of Insured/Individual's No. — Self-explanatory.

Policy No. — Self-explanatory.

Comments — Enter any pertinent comments.

Staff signs the form and enters the date and his telephone number. An insurance company representative completes the other items on the form.

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