Long Term Care Planning Check List

General information Yes No N/A
1. Has relevant personal information been gathered?   [ ]              [ ]               [ ]
• Name   [ ]              [ ]               [ ]
• Date of birth   [ ]              [ ]               [ ]
• Legal state of residence   [ ]              [ ]               [ ]
• Health status, including medications being taken   [ ]              [ ]               [ ]
• Marital status   [ ]              [ ]               [ ]
• Family members available for support   [ ]              [ ]               [ ]
• Name, phone number, and address of attorney, physician, geriatric care manager or other adviser   [ ]              [ ]               [ ]
• Income from Social Security, pension, employment, or other source   [ ]              [ ]               [ ]
• Expenses   [ ]              [ ]               [ ]
• Assets   [ ]              [ ]               [ ]
• Liabilities   [ ]              [ ]               [ ]
Long-term care planning Yes No N/A
1. Is the need for long-term care imminent?   [ ]              [ ]               [ ]
2. Are assets sufficient to cover long-term care needs?   [ ]              [ ]               [ ]
3. Have ways  to fund long-term care been reviewed/evaluated?   [ ]              [ ]               [ ]
4. If homeowner, has home equity as  a use of funds been discussed?   [ ]              [ ]               [ ]
5. Are long-term care insurance benefits available?   [ ]              [ ]               [ ]
6. Have various housing options and their costs been considered?   [ ]              [ ]               [ ]
• In-home care   [ ]              [ ]               [ ]
• Living with a  relative   [ ]              [ ]               [ ]
• Continuing care retirement community   [ ]              [ ]               [ ]
• Assisted living   [ ]              [ ]               [ ]
• Nursing home   [ ]              [ ]               [ ]
Insurance planning Yes No N/A
1. Is adequate health insurance available?   [ ]              [ ]               [ ]
• Medicare   [ ]              [ ]               [ ]
• Medigap   [ ]              [ ]               [ ]
• Private health insurance   [ ]              [ ]               [ ]
• Prescription plans   [ ]              [ ]               [ ]
2. Have Medicaid planning goals and strategies been considered?   [ ]              [ ]               [ ]
3. Has Medicaid qualification criteria been discussed?   [ ]              [ ]               [ ]
4. Has the need for long-term care insurance been established?   [ ]              [ ]               [ ]
5. Is long-term care insurance coverage available to the client?   [ ]              [ ]               [ ]
6. Have existing long-term care insurance policies been reviewed/evaluated?   [ ]              [ ]               [ ]
7. Does long-term care insurance coverage need to be upgraded?   [ ]              [ ]               [ ]
8.  Do long-term care benefits need to be accessed?   [ ]              [ ]               [ ]
Estate planning
1. Has long-term care planning been coordinated with estate planning needs? Yes No N/A
2. Have appropriate estate planning documents been prepared?   [ ]              [ ]               [ ]
• Will   [ ]              [ ]               [ ]
• Trust   [ ]              [ ]               [ ]
3. Have advanced medical directives been prepared?   [ ]              [ ]               [ ]
• Durable power of attorney   [ ]              [ ]               [ ]
• Living will   [ ]              [ ]               [ ]
• Health-care proxy   [ ]              [ ]               [ ]
4. Have letters of instruction been prepared?   [ ]              [ ]               [ ]
5. Has this information been communicated to family members?   [ ]              [ ]               [ ]
Other Yes No N/A
1. Has the need for organizing important documents and records been discussed?   [ ]              [ ]               [ ]
• Bank account records (statements and passbooks)   [ ]              [ ]               [ ]
• Monthly bills to be paid   [ ]              [ ]               [ ]
• Stock certificates, bonds, and other investment records   [ ]              [ ]               [ ]
• Retirement plan statements   [ ]              [ ]               [ ]
• Real estate deeds, mortgages, and other property ownership records   [ ]              [ ]               [ ]
• Vehicle titles   [ ]              [ ]               [ ]
• Business agreements   [ ]              [ ]               [ ]
• Insurance policies   [ ]              [ ]               [ ]
• Will, trust, advanced medical directives, letters of
instruction, and other documents
• Birth certificate, marriage certificate, divorce decree, military service papers