Health Check Application Page 4
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64. Is there a family member living away from the home for less than 12 months (Example: military service,
attending school)?
Yes
No
If yes, please give information below:
Relationship to
Full name (first, middle initial, last)
Reason for absence
Expected date of return
child(ren)
Tell Us About the Family’s Health Insurance and Medical Needs
5. Is there currently a parent not living in the home?
Yes
No
If yes, what is that parent’s name? (optional)
Is that parent required by an agreement to pay for health insurance?
Yes
No
6. Does anyone applying have other health plan/coverage?
Yes
No
If yes, please give information below:
Name of Insured
Insurance
Insurance Company
Insurance Company
Group/Policy
Owner of Policy
(first, middle initial, last)
Company Name
Address
Phone Number
Number
7. Does anyone applying need help paying medical bills from the past three months?
Yes
No
If yes, please give the information below: We may be able to help pay those bills.
Name of person(s) with bill
Name of doctor, clinic and/or hospital where person was
Date of medical treatment
(first, middle initial, last)
treated
8. Has anyone applying been in an accident in the past 12 months?
Yes
No
Did he/she receive medical care because of the accident?
Yes
No
If yes, please tell us who.
When was the accident?
Tell Us About the Parent’s and Children’s Income
9. Who are the parents and children in the home who work and what are their wages?
Amount
How often paid
Name of working person
Tips
Employer's name and phone number
earned before
(monthly, weekly,
(first, middle initial, last)
earned
deductions
etc.)
Please provide copies of all of last month’s paycheck stubs for everybody listed. Send in the application even if you do
not have your stubs.
DMA-5063 (02-2012)
Questions about Health Check/ Health Choice? Call 1-800-662-7030.
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Parent category: Business