2003 Application & Renewal Form (Page 3 of 6) in pdf

Section H: Day Care Expenses -

If you or anyone in the household pay for day care for a child or a disabled adult complete the following. Also, include any day care

payments made by a state agency such as the Care4Kids Program.

Name of Person who

Amount Paid

Amount Paid by

Day Care Provider Name, Address

How Often?

Receives Care

By You

the State

And Phone Number

Section I: Health Insurance -

Does anyone for whom you are applying currently have other health insurance? ❑ Yes ❑ No

If yes, please complete the following.

Insurance Company Name, Address,

Policy or

Begin

Name(s) of Insured

Type

Source

and Phone Number

Member Number

Date

❑ Employer-Sponsored

❑ Medical ❑ Vision

❑ Municipal/State

❑ Dental

❑ Pharmacy

Employee

❑ Other

❑ Private (self-pay)

Did anyone have employer-sponsored health insurance terminated or canceled in the last two months? ❑ ❑ ❑ ❑ Yes ❑ ❑ ❑ ❑ No If yes, complete the following:

Insurance Company Name, Address,

Policy or

Date

Why is this Insurance No

Name of Insured

Type

and Phone Number

Member Number

Ended

Longer Available?

❑ Medical ❑ Vision

❑ Dental

❑ Pharmacy

❑ Other

How much do you pay, or did you pay for this insurance? $______________ How often? ___________________.

If anyone in the household has unpaid medical bills, paid bills for medical services received in the past 3 months, or is currently paying on a loan

that was taken to pay for medical bills, please provide the following information. We may need more information about your medical bills later.

Date of Medical

Amount Still

Amount Paid

If you took a loan to pay for medical care, give the Name of the Lender, Amount

Total Charge

Service

Owed

Each Month

of the Loan and the Date the Loan was Taken

Section J: Immigration -

Provide immigration information for those who are not citizens and who are applying for HUSKY health insurance.

Date of US

Date Status

Blind or

Receives

Member of US Armed Forces or

Name

INS Number

INS Status

Entry

Received

Disabled?

SSI?

Veteran or Child or Spouse?

❑ Yes ❑ No

❑ Yes

❑ No

❑ Yes ❑ No

❑ Yes

❑ No

Section K: Tribal Membership -

Members of federally recognized American Indian tribes and Alaskan Natives who qualify for subsidized HUSKY coverage do not have

to pay premiums or co-payments. Are any of the people listed in Section B or C members of a federally recognized American Indian tribe or Alaskan Natives? ❑ Yes ❑ No If

yes, list the person’s name and tribe and provide a tribal card or letter as verification__________________________________________________________________________

IF YOU HAVE ANY QUESTIONS ABOUT THIS APPLICATION OR NEED HELP COMPLETING IT, CALL 1-800-656-6684.

W-1HUS (Revised 4/2003)