Hill Country Mission for Health

Hill Country Mission for Health

Patient Eligibility Screening

Date of Evaluation: ______Language Spoken ___ English ___ Spanish Other______

Have you ever received services at HCMfH? ___ Yes ___ No If so, when ______

Patient Name:______Home# ______Cell#______

Date of Birth ______Age 18-64: ______SS#______

Male or Female?______Females: Are you pregnant? ___ Yes ____ No

Marital Status: ____Single ___Married ____Divorced ___Separated ___ Widow(er)

Physical Address (No P.O. Box): ______

City: ______State: ______County: ______Zip: ______

Kendall County Resident? _____Yes ___ No Area: Boerne ______Comfort ______

Race: ___ Asian ___ African American ___ Caucasian ___ Hispanic/Latino ___ Native American

___ Pacific Islander ___ Other

Do you have any Health Insurance? ____ Yes ____ No If so, what type ____Medicaid ___ Medicare ____ VA Health Benefits ___Workers Compensation Benefits_____ Affordable Care Act Other______

Are You Employed? ___ Yes ____ No Name of Employer: ______

Are you a Veteran? ___ Yes ___ No

Do you have photo ID? __ Yes ____ No (Must bring to first visit and copy retained in patient chart)

Emergency Contact Name: ______Phone# ______

Name
(The first person on list is yourself) / Relationship
(Spouse/Child) / Social Security # / Sex
M/F / Date of Birth (MO/Day/YR) / Work
(Yes/No) / Income

Members of Household, Including Self

What type of Medical Services are needed now?______

Place previous Medical care received: ______

How did you hear about this clinic? ______

Church Affiliation? ______

Is any member of your family RECEIVING any of the following?Please indicate foreach Yes or No:

___ Yes ____ No Medicaid / ___ Yes ____ No TANF
___ Yes ____ No CHIP / ___ Yes ____ No Food Stamps
___ Yes ____ No Medical Insurance / ___ Yes ____ No Workman’s Compensation
___ Yes ____ No Dental Insurance / ___ Yes ____ No Alimony
___ Yes ____ No VA Medical / ___ Yes ____ No Pension Benefits
___ Yes ____ No Unemployment Benefits / ___ Yes ____ No SSI – Supplemental Security Income
___ Yes ____ No Medicare / ___ Yes ____ No Child Support

I certify that the information I have given is up-to-date and correct. I understand that any falsification, misrepresentation, or withholding of information will result in the loss of eligibility to receive clinic services.

Printed name: ______Signature: ______Date: ______

Below Section Completed by Interviewer

___ New Applicant ___Applicant Renewal

Total (Household) Income for all adults? Monthly:______Annually:______

Income Verified with ______

Income Verification Includes: previous year’s income tax return, unemployment benefits, child support, disability check, retirement check, three months of paycheck stubs, food stamp verification, rental income, and all other proof of income. Proof of income will be verified prior to patient seeing provider.

Photo IDIncludes: driver’s license, passport, visa, immigration documents, student or work, photo ID from other country, or other form of photo identification. Valid Photo ID will be verified prior to patient seeing provider.

Type of Photo ID attained: ______

Printed name of Interviewer: ______Date: ______

\\MFH-SERVER\RedirectedFolders\chrystal\Desktop\Patient Screening Memo\Eligibility Screening for New Patients Rev 1-23-2017.docx Rev. 2/4/15