Health Check Application Page 5
Download a blank fillable Health Check Application in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Health Check Application with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
610. Is there anyone in the home who is self-employed?
Yes
No
For example, does anyone earn money from farming, own his or her own business, or have rental property income?
If yes, please attach business records showing income and expenses for the last 6 months or the number of months in
business if less than 6 months. If the income is annual, please attach business records for the last 12 months.
11. Has anyone in the home lost a job in the past three months?
Yes
No
If yes, please complete the following:
Name of person(s) who lost
Former employer's address & phone
Date job lost
Former employer’s name
a job
number
12. If the parent or child receives income from any other source please complete the blocks below.
How often received
Type of income
Name of the person who receives other income
Amount received
(monthly, weekly,
etc.)
$
Child Support:
$
Social Security:
$
Unemployment:
Other (Please explain):
$
Tell Us About the Parent’s and Children’s Expenses
Some of these expenses may be used to reduce the income that we count to determine enrollment in Health Check
(Medicaid)/Health Choice.
13. Does a working parent living in the home pay for childcare, a babysitter or care for a dependent adult?
Yes
No
If yes, please fill in the information:
Name, address & phone number of
Name of person
Name of person paying
Amount paid
How often paid
sitter or care provider
cared for
for care
(monthly, weekly,
etc.)
14. Does a parent living in the home pay child support for a child who is not living in the home?
Yes
No
If yes, please fill in the information.
How often paid
Amount paid
Who pays the support & to
Is it court
For whom is the support paid
(monthly, weekly,
Please Attach
whom
ordered? (Y, N)
Verification
etc.)
$
$
$
DMA-5063 (02-2012)
Questions about Health Check/ Health Choice? Call 1-800-662-7030.
Page 5
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business