Effective Date: 
3/2012

Documents


Instructions

Updated: 3/2012

Purpose

To provide a written statement that a countable resource has been designated for the Long-Term Care Partnership (LTCP) disregard.

Procedure

When to Prepare

Complete Form H0056 so a person may designate a countable resource for the LTCP disregard.

The applicant, recipient or Responsible Person signs the Form H0056.

Number of Copies

Complete an original and one copy.

Transmittal

HHSC staff file the original in the case record upon return and gives the copy to the applicant, recipient or his responsible person.

Form Retention

Form H0056 is kept permanently in the case record.

DETAILED INSTRUCTIONS

Inside Address — Enter name and address of person and/or the authorized representative..

Date — Self-explanatory.

Eligibility Specialist — Self-explanatory.

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

Name — Self-explanatory.

Individual's No. — Self-explanatory.

You have a Long-Term Care Partnership (LTCP) disregard balance available to you in the amount of $ — Self-explanatory.

Enter the Countable Resource information, the Equity Value and the Name/Address/Location of all countable resources.

The applicant, recipient or Responsible Person checks the Yes box next to the countable resource(s) they wish to designate for the LTCP disregard, fills in the amount designated and completes the following information:

Name of person Completing the form — Self-explanatory.

Signature — Obtain the signature of the individual or responsible person.

Date — Self-explanatory.

Signatures of Witnesses — The signatures of two witnesses are entered, if required.

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