Medicaid Online Questionnaire

Please answer the following questions, to get the application process started.

If a question doesn’t apply to you, simply enter “N/A.” If you are unsure about the value (or even existence) of an asset or income, simply enter “TBD” (to be determined) for now. 

Please keep in mind that the questions relate to one individual. Therefore, if you are married, we also need to know your spouse’s information for all questions (especially re your spouse’s income & assets). 

After completing this questionnaire, please submit the supporting documents for each of your (and our spouse’s) income and asset. Note: even if an income is reflected on your bank statement, we still need the actual income statement. For example, even if you receive your pension or social security benefits via direct deposit, we still need the actual pension or social security statement. 

You may submit your supporting documents via the Secure Client Portal, via email at Abraham@Mazloumi.com, or via fax at 516-283-0250.

Name of Health Insurance Company

Enter -0- if none or TBD if unknown

Enter -0- if none or TBD if unknown

Enter -0- if none or TBD if unknown

Enter -0- if none or TBD if unknown

Enter -0- if none or TBD if unknown

Enter -0- if none or TBD if unknown

Enter -0- if none or TBD if unknown

Enter -0- if none or TBD if unknown

Enter -0- if none or TBD if unknown

Enter -0- if none or TBD if unknown

Enter -0- if none or TBD if unknown

Enter -0- if none or TBD if unknown

Enter -0- if none or TBD if unknown

Enter -0- if none or TBD if unknown

Enter -0- if none or TBD if unknown

Enter -0- if none or TBD if unknown

Enter -0- if none or TBD if unknown

Enter -0- if none or TBD if unknown

Enter -0- if none or TBD if unknown

Enter -0- if none or TBD if unknown

Enter -0- if none or TBD if unknown

Enter -0- if none or TBD if unknown

Enter -0- if none or TBD if unknown

Enter "0" if none or TBD if unknown

Enter TBD if unknown

Few areas of the law are as complex and potentially frustrating as Medicaid planning and applications. The complex regulations and requirements of New York Medicaid are constantly evolving, making the risk of failure quite real. A small mistake can result in a denial of coverage, and significant financial losses. The legal team at Abraham Mazloumi & Associates has detailed expertise in New York State Medicaid law, guiding clients through the Medicaid application process and ensuring eligibility is obtained at a success rate that is unrivaled.

Our attorneys are experts in the Medicaid guidelines and their implications, and can identify the specific approach that your case requires so that your application is prepared and filed properly, and ensuring you a secure financial future. We represent you before the local Medicaid agency and we communicate directly with Medicaid workers on both the County and State levels enabling us to deal with issues in the most efficient manner possible. Our relationships allow us to have the Medicaid applications expedited and given the proper attention by the County worker assigned to each case.

Our staff makes themselves readily available to our clients if any questions may arise at any point during the application process. We establish working relationships with the clients and their families through every step of the process implementing the advice given from start to finish. With our help, you can approach the Medicaid application process confidently, knowing that you have the best available information, preparation and support from our team. 

Contact us today to begin the conversation.

To speak with an attorney, please call Mazloumi Law at 516-466-7526 or email us at info@mazloumi.com to set up a consultation at your convenience.