Get Pa1572

The Pa1572 Resource Assessment Form is an essential document for couples when one partner is receiving long-term care services. This guide provides clear and supportive instructions to help users complete the form online accurately.

Follow the steps to successfully complete the Pa1572 online.

1. Click ‘Get Form’ button to access the Pa1572 online and open it in the document editor.
2. Begin by filling out your personal information at the top of the form, including your last name, first name, middle initial, address, date of birth, and social security number.
3. Next, provide the same details for your spouse, including their last name, first name, middle initial, address, date of birth, and social security number.
4. In the resources section, list all resources owned by both you and your spouse as of the date of admission to the nursing facility or HCBS assessment date. Be thorough to ensure no resources are omitted.
5. For each resource you list, select the corresponding resource code provided in the form, indicating the total value, amount owed, and net value. Ensure you have verification documentation for every resource.
6. Complete the life insurance section, detailing each policy, including the name of the insured, the insurance policy number, beneficiary name, face value, cash value, and confirmation of whether this information has been documented.
7. If applicable, provide information about any legal representatives, ensuring to include a valid contact method and relationship to the individual in need of long-term care services.
8. Sign the form at the end, indicating your relationship to the individual requiring services, and date the signature.
9. Review your completed form carefully against the checklist included, ensuring all sections are filled and that you attach relevant photocopies of verification documentation.
10. Once all information is complete and verified, submit the Pa1572 to your local county assistance office where the nursing facility is located or where HCBS is being received.

Complete the Pa1572 online today to manage your long-term care resources effectively.