Trusted Non-Profit
Designated VA Fiduciary & Social Security benefit administrator.
BalancedCare Medicaid Forms
These are the forms involved in creating the Pooled Trust. We understand this can all seem daunting. We do have strategic relationships with non-profits in your area that can help you submit your Medicaid application. If you could use some help, give us a call.
Medical Report
for Determination
of Disability
DOH-5143
Click to Download
Authorization
to Release
Medical Information
MAP-751E
Click to Download
New York State
Disability
Questionnaire
DOH-5139
Click to Download
New York State
HIPPA
Release Form
DOH-5173
Click to Download
Sample New
York State
HIPPA
Release Form
Click to Download
Disability
Determination
Request
MAP-3177
Click to Download
Why Choose BalancedCare for a Pooled Trust?
Exceptional Support
Our staff offers knowledgeable, compassionate customer service.
Simple to get started
Our staff will help you through the entire application process.
Low Maintenance Fees
As a non-profit agency, we maintain some of the lowest industry fees.
No Minimum Balance
You do not need to carry excess money to keep an active account.
24/7 Client Portal Access
View your account activity anytime, to review payments, deposits, etc.
Automatic Bill Paying
All applicable bills will be setup to be paid automatically, on time.
Automated Deposits
We setup direct deposits to your account, from your account.
Pooled Trust Completion
BalancedCare will submit your pooled trust packet to Medicaid
Need help with Medicaid?
Our certified counselors can help you understand what's required to qualify for Medicaid benefits and how a Pooled Trust can help you live in your own home and keep your excess income. Having trouble? Our counselors can put you in contact with a non-profit agency in your area that can help you submit your Medicaid application.
Contact Us
Interested in learning more about BalancedCare Pooled Trusts or to Get Started? Call 585-360-1854 or use the form below.