Pbv Application Packet - Housing Authority Of Snohomish County Page 15
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385. Do you pay for any medical, dental, or vision insurance for you or any member of your
Yes
No
family?
If yes, please complete the table below: You must provide supporting documentation.
Medical Insurance Provider Name
and Phone
Family Member Name
Policy Number
Premium Cost
6. Do you make regular payments to any doctor or medical facility for yourself or any
Yes
No
family member?
If yes, please complete the table below. You must provide supporting documentation.
Family Member Name
Doctor or Medical Facility Name
Phone / FAX #
Payment amount per
and Address
month
$
$
7. Do you pay for any prescriptions for any family member?
Yes
No
If yes, please provide a print out from your pharmacy showing the prescriptions and the amounts
paid out of pocket for the last 12 months.
8. Do you pay for a care attendant or medical equipment out of pocket?
Yes
No
If yes, please list the agency or individual you pay and how much you pay out of pocket each
month for the service or equipment. You must provide supporting documentation.
6
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