[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"doc-seo-306301-105":3,"doc-detail-306301-en":81,"detail-sidebar-cat-1-en-105":98},{"code":4,"msg":5,"data":6},0,"ok",{"site_id":7,"language":8,"slug":9,"title":10,"keywords":11,"description":12,"schema_data":13,"social_meta":74,"head_meta":76,"extra_data":78,"updated_unix":80},105,"en","medicaid-medicare-savings-form-700-application","Medicaid & Medicare Savings Form 700 - Application","","Georgia Medicaid and Medicare Savings program application form for Qualified Beneficiaries, including QMB premium/coinsurance/deductible coverage, SLMB Part B premium coverage, and QI-1 Part B premium coverage. Includes step-by-step instructions to complete responses accurately, provide signatures, and submit to County DFCS, with possible telephone interview requirements. Collects personal and spouse information, living arrangement details, Medicare and other insurance enrollment data, real property and vehicle listings, resources and life insurance policy information, and income sources with amounts and frequency.",{"@graph":14,"@context":73},[15,34,56],{"@type":16,"itemListElement":17},"BreadcrumbList",[18,23,27,31],{"item":19,"name":20,"@type":21,"position":22},"https://docshare.wps.com","Home","ListItem",1,{"item":24,"name":25,"@type":21,"position":26},"https://docshare.wps.com/template/","Template",2,{"item":28,"name":29,"@type":21,"position":30},"https://docshare.wps.com/template/forms/","Forms",3,{"item":32,"name":10,"@type":21,"position":33},"https://docshare.wps.com/template/medicaid-medicare-savings-form-700-application/306301/",4,{"url":32,"name":10,"@type":35,"image":36,"author":41,"headline":10,"publisher":44,"fileFormat":47,"inLanguage":8,"description":12,"dateModified":48,"datePublished":49,"encodingFormat":47,"isAccessibleForFree":50,"interactionStatistic":51},"DigitalDocument",{"url":37,"@type":38,"width":39,"height":40},"https://docshare.wps.com/thumbnails/medicaid-medicare-savings-form-700-application/306301.png","ImageObject",442,249,{"name":42,"@type":43},"Quinn","Person",{"url":19,"name":45,"@type":46},"DocShare","Organization","application/pdf","2026-10-27","2026-09-19",true,{"@type":52,"interactionType":53,"userInteractionCount":55},"InteractionCounter",{"@type":54},"ViewAction",13,{"@type":57,"mainEntity":58},"FAQPage",[59,65,69],{"name":60,"@type":61,"acceptedAnswer":62},"Where should the completed application be mailed or delivered?","Question",{"text":63,"@type":64},"Send or deliver the signed application to the County DFCS office in the applicant’s county of residence.","Answer",{"name":66,"@type":61,"acceptedAnswer":67},"What kinds of program coverage are covered by this application?",{"text":68,"@type":64},"It covers QMB for premiums, coinsurance, and deductibles; SLMB for Part B premium; and QI-1 for Part B premium.",{"name":70,"@type":61,"acceptedAnswer":71},"What information is required for Medicare and other health insurance?",{"text":72,"@type":64},"Provide whether Medicare is held, type of coverage (Part A/Part B/Part D), effective dates, Medicare numbers, and whether a spouse has Medicare. Also list other health insurance details if applicable, including company information, type of coverage, effective date, and policy number.","https://schema.org",{"og:url":32,"og:type":75,"og:title":10,"og:site_name":45,"og:description":12},"article",{"robots":77,"canonical":32},"index,follow",{"doc_id":79,"site_id":7},306301,1790226691,{"code":4,"msg":82,"data":83},"success",{"doc_id":79,"user_id":84,"nickname":42,"user_avatar":85,"doc_module":22,"category_id":86,"category_name":29,"doc_title":10,"doc_description":12,"doc_content":87,"file_id":88,"file_url":89,"file_type":90,"file_size":91,"view_count":55,"is_deleted":4,"is_public":22,"is_downloadable":22,"audit_status":22,"page_count":92,"language":93,"language_code":8,"site_id":7,"html_lang":8,"table_of_contents":94,"faqs":95,"seo_title":96,"seo_description":12,"update_tm":97,"read_time":26},962075114765,"https://ap-avatar.wpscdn.com/davatar_a8503ba1806abce46bf441b54a3ca4cd",17,"Georgia Application for Medicaid & Medicare Savings for Qualified Beneficiaries  \n(QMB-payment of premiums, coinsurance, and deductibles; SLMB-payment of Part B premium; and QI-1-payment of Part B premium)  \nINSTRUCTIONS:  \n1. Read the application carefully & answer each question accurately. Attach additional pages if needed.  \n2. Sign and mail application to:   County DFCS  \n(Mail or deliver application to the DFCS   office in your county of residence)  \n______________________________________  \n______________________________________  \nATTN:    \n3. A telephone interview may be required for these programs. Be sure to enter phone \\# below.  \n4. The DFCS Medicaid Specialist will review this application. If it appears that you may be eligible for full Medicaid coverage, the Medicaid Specialist will contact you for more information and verifications.  \nPERSONAL INFORMATION: You may have someone help you complete this application.  \n\n| Applicant’s Name (Last, First, Middle Initial) | If you wish to name a person to act on your behalf, complete the information below:\u003Cbr>Name (Last, First, Middle Initial) |\n| --- | --- |\n| Mailing Address |  |\n| Street Address | Mailing Address |\n| City State Zip\u003Cbr>Do you own/are you purchasing home? □ Y □ N | City State Zip |\n| Phone County\u003Cbr>E-Mail Address | Phone\u003Cbr>E-Mail Address |\n| Nursing Facility (if applicable) | Relationship to Individual |\n\nCOMPLETE THIS INFORMATION FOR YOU AND YOUR SPOUSE.  \n\n| Name (Self):\u003Cbr>Maiden/other name(s): | Birthdate | Sex | Race | U. S. Citizen\u003Cbr>(Yes or No) | Social Security Number | Marital\u003Cbr>Status |\n| --- | --- | --- | --- | --- | --- | --- |\n| Name (Spouse):\u003Cbr>Maiden/other name(s): |  |  |  |  |  |  |\n\nAre you applying for your spouse, too? □ Yes □ No  \nAre you blind or disabled? □ Yes □ No -Is your spouse blind or disabled? □ Yes □ No LIVING ARRANGEMENT: Check the box(es) that best describes your current situation.  \n\n| Living In Own Home | Nursing\u003Cbr>Facility | Another’s Home | Hospice | Hospital | Katie Beckett | Community Care | Assisted Living | Other/\u003Cbr>Renting |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- |\n|  | Date\u003Cbr>Admitted: |  |  | Date\u003Cbr>Admitted: |  | Date\u003Cbr>Admitted: |  |  |\n\nHEALTH INSURANCE:  \n\n| Do you have Medicare? | Type of Coverage | Effective Date: | Have you ever |\n| --- | --- | --- | --- |\n| □ Yes □ No | □ Part A □ Part B | ______________ | received SSI? |\n| Are you enrolled in a Medicare | (hospital) (doctor) |  | □ Yes □ No |\n| HMO or Medicare Drug program? | Part D | Medicare Number: | If so, when did it |\n| □ Yes □ No | (RX) | ____________ | end?  |\n| Does your spouse have Medicare?\u003Cbr>□ Yes □ No | Type of Coverage\u003Cbr>□ Part A □ Part B\u003Cbr>Part D | Effective Date:\u003Cbr>Medicare Number:\u003Cbr>____________ | Has your spouse ever received SSI?\u003Cbr>□ Yes □ No If so, when did it end?  |\n\nDo you have other health insurance?  \nDoes your spouse have other health insurance?  \n□ Yes  \n□ Yes  \n□ No  \n□ No  \nIf you answered yes to either of these questions, please complete the following information:  \n\n|  | Health Insurance Company Name, Address, and Telephone Number | Type of Coverage (Hospital, Medicare Supplement, Drugs, Major Medical,) | Effective Date | Policy Number |\n| --- | --- | --- | --- | --- |\n| Self |  |  |  |  |\n| Spouse |  |  |  |  |\n\nAttach copies (front and back) of Medicare and insurance cards if applicable.  \nREAL PROPERTY: Do you own all or part of any real estate in which you do not live? □ Yes □ No If yes, please complete the following for each piece of real estate. Do not list the house or mobile home in which you live.  \n\n| Address | Value | Amount Owed |\n| --- | --- | --- |\n|  |  |  |\n|  |  |  |\n\nDo you or your spouse own a car, truck, boat, camper, utility trailer, recreational vehicle, etc.?  \n□ Yes □ No If yes, please complete the following information about each vehicle. Attach  \nadditional pages if needed.  \n\n| Type | Year | Make | Model | Value | Amount Owed |\n| --- | --- | --- | --- | --- | --- |\n","cbCaiup8KFeAP4D3","https://ap.wps.com/l/cbCaiup8KFeAP4D3","pdf",72535,5,"English","# Instructions\n# Personal Information\n# Living Arrangement\n# Health Insurance\n# Real Property\n# Resources\n# Income and Earnings","[{\"question\":\"Where should the completed application be mailed or delivered?\",\"answer\":\"Send or deliver the signed application to the County DFCS office in the applicant’s county of residence.\"},{\"question\":\"What kinds of program coverage are covered by this application?\",\"answer\":\"It covers QMB for premiums, coinsurance, and deductibles; SLMB for Part B premium; and QI-1 for Part B premium.\"},{\"question\":\"What information is required for Medicare and other health insurance?\",\"answer\":\"Provide whether Medicare is held, type of coverage (Part A/Part B/Part D), effective dates, Medicare numbers, and whether a spouse has Medicare. Also list other health insurance details if applicable, including company information, type of coverage, effective date, and policy number.\"}]","Medicaid & Medicare Savings Form 700 - Application | PDF",1789835189,{"code":4,"msg":82,"data":99},[100,105,110,115,120,125,128,133,137],{"id":101,"doc_module":22,"doc_module_name":25,"category_name":102,"show_sort_weight":103,"slug":104},11,"Presentations",90,"presentations",{"id":106,"doc_module":22,"doc_module_name":25,"category_name":107,"show_sort_weight":108,"slug":109},12,"Resumes",80,"resumes",{"id":111,"doc_module":22,"doc_module_name":25,"category_name":112,"show_sort_weight":113,"slug":114},14,"Invoices",70,"invoices",{"id":116,"doc_module":22,"doc_module_name":25,"category_name":117,"show_sort_weight":118,"slug":119},15,"Posters",60,"posters",{"id":121,"doc_module":22,"doc_module_name":25,"category_name":122,"show_sort_weight":123,"slug":124},16,"Social Media",50,"social-media",{"id":86,"doc_module":22,"doc_module_name":25,"category_name":29,"show_sort_weight":126,"slug":127},40,"forms",{"id":129,"doc_module":22,"doc_module_name":25,"category_name":130,"show_sort_weight":131,"slug":132},18,"Letters",30,"letters",{"id":134,"doc_module":22,"doc_module_name":25,"category_name":135,"show_sort_weight":92,"slug":136},21,"Paper Templates","papers-templates",{"id":138,"doc_module":22,"doc_module_name":25,"category_name":139,"show_sort_weight":4,"slug":140},158,"General","general-158"]