Skilled Nursing Facility Referral Page

Hello! You have reached this page because you have a resident or potential new resident that will benefit from Estate, Medicaid and/or VA planning.

Here are the next steps:

1. Contact our office directly (or have the family contact) and speak with my Case Manager, Courtney Haug at 740-452-8484.
2. Complete the following form:

Name of resident / potential resident *

First

Last

Mailing address *

Address Line 1

Address Line 2

City

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingState

Zip Code

Phone *

Email

Type of facility *Skilled nursingSkilled nursing / assisted living

Comment or Message

Is the person currently on Medicaid? *

• Yes
• No

Is the person in a Medicaid approved room? *

• Yes
• No

Has a Medicaid application been filed? *

• Yes
• No

Is the person a Veteran or Widowed Spouse of a Veteran? *

• Yes
• No

Do they own more than $10,000 in cash or other investments? *

• Yes
• No

Do they own a home? *

• Yes
• No

Do they have an IRA?

• Yes
• No

Admission date (or projected admission date)

Any previous nursing home stays for 30 days or longer? If so, please provide approximate dates.

Submit