INTAKE AND ELIGIBILITY FORM

This form is used by staff (who may or may not be case managers) to obtain and document required information to determine a person’s eligibility to receive HIV/AIDS medical and support services under the Mecklenburg County Transitional Grant Area (TGA).

Date of Initial Contact: / / Date Intake/Eligibility Initiated: / /
______
Case Manager Signature Date Intake Completed

a. Personal/Contact Information

NAME Soc.Sec.No.
Address City/Township
County State Zip Code
Referred By Phone
Phone (H) ( ) (W) ( ) (Emg) ( )
Date of Birth Race Language
Client provided proof of residency: Y N
Client Preference for Contact (circle) Phone Message Office Visit Home
Can talk to: 1.______2.______
Is it O.K. to include HIV/AIDS info in day phone contact? Y N
Is it O.K. to include HIV/AIDS info in evening phone contact? Y N
Is it O.K. to include HIV/AIDS info in mail? Y N
Gender: M / F / Trans
Ethnicity: White / African-American / Hispanic / Native American / Asian-Pacific
Marital Status: S / M / P* / D / W Household Size:
Comments:
Employed: Yes / No Name of Employer:
HIV Positive? Yes / No / Date of Test: / / Test Location:
AIDS Diagnosis? Yes / No Date of AIDS Diagnosis: / / CD4: Date of CD4: / /
Client Statement of Needs:

*Partner

b. Screening for Medicaid and Other Programs

1. Indicate the results of the Medicaid verification:

Eligible
Y/N / Date / /
Medicaid Cap C Program
Medicaid Cap DA Program
Medicare
Dually Eligible for Medicaid and Medicare
Medicaid HMO

2. Indicate Other Program Participation.

Eligible
Y/N
ADAP - AIDS Drug Assistance Programs
AICP - AIDS Insurance Continuation Program
North Carolina Health Choice for Children
WIC – Women, Infants and Children and Nutrition Services
HOPWA – Housing Opportunities for People With AIDS
Local Indigent Programs
Department of Social Services -
Emergency Assistance Program
Veterans Administration
Department of Social Services Food Stamps
Subsidized Child Care
Employment Securities Commission
Other

3.  Insurance Information

Do you have any other health insurance? Y N If no, skip to next section
Is your health insurance through your current or previous employer?
If through your previous employer, DATE Cobra coverage began: / /
Name of Insurance Company:
Address:
Phone: ( )
Group #: Policy #:

c. Client Financial Assessment

Y/N / Income /

Amount

/ Notes
Unemployed / How Long:
Wages or Salary: / Name of Employer:
Address:
Tips
Self-Employment: / Name of Employer:
Address:
Social Security Benefits
Temporary Assistance to Needy Families
Program
Worker’s Compensation
Unemployment Compensation
Other insurance benefits
Trust Fund
Retirement Benefits
Assistance given by relative and/or friends
Income from rental of personal property
Other monthly assistance from welfare agencies,
public or private
Child Support and/or Alimony received
Total Annual Income / (A)

1. Name and amount of income for all adult family members 18 and over

Name Relationship Amount of Income

Total Annual Income / (B)

Add ______+______= ______

A B Total Income

Determine a client’s family size and gross family income on the Federal Poverty Guidelines and locate the poverty level percent that corresponds to the client’s gross income and family size on the Federal Poverty Guidelines.

2. Check which documentation provides proof of income and attach copies to this form:

Type of Income / Documentation
Employment Income / ____ Pay check stub for the past month,
____ Signed employer statements with dates,
____ Position and phone number or income,
____ Tax return
Child Support Payments / ____ Court Order/Copy of Check
Social Security (SSDI, OASDI) / ____ Social Security Award Letters
Supplemental Security Income (SSI) / ____ Statement/Award Letter
VA Benefits / ____ Statement/Award Letter
Retirement Benefits / ____ Award Letter/Copy Check
Interest income or other investment income / ____ Bank Statements
Other Cash Support / ____ Family and Friends
____ Other Appropriate and Related
Other

d. Residency

YES NO

The person is living in the state of North Carolina at the time of the
eligibility determination:
Client provided the following as proof:
A physical living address (as well as a mailing address if the two
are not the same):
The person is a resident of North Carolina
If no, the person was referred to______for
additional services.

e. Must Be Willing To Sign All Forms and Provide Eligibility Documentation

YES NO

The person is willing to sign all forms and provide all appropriate
documentation to assist with the eligibility determination process in an expeditious manner.

Eligible ______Y ______N Comments: ______

______

Client Signature: ______Date: ______

Case Manager: ______Date: ______

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