Form Hc 201p - Pharmacy Programs Application Form - Vermont Department For Children And Families Page 2
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28. Do you or your spouse or civil union partner have health insurance?
Yes
No
8a. Policy holder
Services (check all that apply)
Names of people covered
8b. Policy #_____________ Group #____________
Doctors
Prescriptions
8c. Date coverage began
Hospitals
Major Medical
8d. Premium $__________ per __________
Outpatient
Other__________
8e. Name of insurance company
8f. Company address & phone #
9. Have you or your spouse or civil union partner lost health insurance in the past 12 months?
Yes
No
(Do not include state health care programs)
9a. Name of person
9b. Date insurance ended
9c. Reason why insurance ended
Please list all current gross income (before taxes, Medicare, and other deductions) for yourself and your spouse or civil union partner, if he or
she lives with you. Please answer all questions.
APPLICANT
SPOUSE OR CIVIL UNION PARTNER
TYPE OF INCOME
AMOUNT
AMOUNT
(before deductions)
(before deductions)
Social Security retirement
$
per mo.
None
$
per mo.
None
Social Security disability
$
per mo.
None
$
per mo.
None
SSI
$
per mo.
None
$
per mo.
None
Railroad retirement
$
per mo.
None
$
per mo.
None
Veteran’s benefits
$
per mo.
None
$
per mo.
None
Pensions or annuities
$
per mo.
None
$
per mo.
None
Interest or dividends
$
per mo.
None
$
per mo.
None
Self-employment, including rental
$
per yr.
None
$
per yr.
None
(If yes, please send copy of most recent federal income tax return including all schedules.)
Wages in last 30 days
$
None
$
None
______________________________________ ______________________________________
Employer
Hrs. per wk.
Hourly wage
Employer
Hrs. per wk.
Hourly wage
Other income in last 30 days
$
None
$
None
(Such as unemployment, worker’s compensation, or alimony)
Please describe____________________________________________
____________________________________
Do you pay for day care for
a child or an incapacitated adult?
$
per month
No
$
per month
No
Do you pay child support or alimony? $
per month
No
$
per month
No
Please read the following rights and responsibilities and sign below:
The information I have provided is correct to the best of my knowledge. I
value of the prescription discounts I received and may subject me to civil or
understand this information may be verified. I understand that I must report all
criminal prosecution.
changes, such as changes in income, insurance, address, and household size. I
I understand that I have the right to treatment that is fair and does not
understand the information I have given is private and cannot be seen by the
discriminate. I may not be treated differently because of race, color, national
public.
origin, marital status, sex, sexual orientation, age, religion, political beliefs, place
I understand that federal regulation requires that I provide my social security
of birth, or because of physical, mental, or emotional conditions. If I have a
number and that it may be used to check my statements with other agencies,
complaint about being treated differently, I may contact the Office for Civil Rights,
such as the Social Security Administration and the Internal Revenue Service, and
Health and Human Services, Room 506-F, 200 Independence Avenue, S.W.,
for quality control reviews. This requirement may be waived for members of a
Washington D.C. 20201. If I believe I have been discriminated against because of
religious organization that objects to furnishing a social security number.
a disability, I may contact: Deputy Commissioner, Department for Children and
Families, Economic Services Division, 103 South Main Street, Waterbury, VT
I understand that intentionally making a false or misleading statement, or
05671-1201.
concealing or withholding facts, may result in paying the Department, in cash, the
I have reviewed the statements above about my rights and responsibilities and I understand them.
Signature of applicant, authorized representative or legal guardian
Date
Signature of person witnessing or helping to fill out this form
Telephone #
If you have an authorized representative or legal guardian, please provide:
Name: ___________________________________________________________________ Telephone #: _________________________
Address: ______________________________________________________________________________________________________
After signing this form, please mail it to: ADPC, 103 South Main Street, Waterbury, VT 05671-1500
If you have questions or for current income levels, call Health Access Member Services at 1-800-250-8427.
To use telephone service for people with hearing disabilities, call 1-888-834-7898.
If you are struggling to make ends meet, call 1-800-287-0589 for a 3SquaresVT application.
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