Form Dhcs 8699 - Recipient Eligibility Form - California Department Of Health Care Services
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3State of California—Health and Human Services Agency
Department of Health Care Services
Every Woman Counts
RECIPIENT ELIGIBILITY FORM
Medical Record Number
Recipient ID
This section to be completed by recipient
1. Last Name
2. First Name
3. Middle Initial
4. Date of birth
5. Mother’s Maiden Name
(MM) (DD) (YYYY)
6. Address
7. City
8. State
9. ZIP Code
10. Telephone
Asian Indian
Cambodian
Chinese
11. Are you Hispanic or Latino?
Filipino
Yes
No
Unknown
Japanese
American Indian or Alaska Native
Korean
12. Select all that apply to you
Asian
13.(
)
Laotian
Select one if Asian
Black or African American
Vietnamese
Pacific Islander
Other Asian
White
Unknown
Guamanian
14.(
)
Hawaiian
Select one if Pacific Islander
Samoan
Other Pacific Islander
15. Total household income (before taxes):
16. Total number of persons living together
on this income:
17. Health insurance:
17a. Do you have health insurance?
17b. If Yes, which type?
Yes
No
Medi-Cal
Medicare Part B
Military
Family PACT
Private insurance
Other
18. Tobacco Use:
**18a. Do you smoke tobacco now?
Yes
No
**18b. Do you use other tobacco products now?
Yes
No
I certify that the above information is correct and complete:
Recipient Signature
Date Signed
PROVIDER USE ONLY Eligibility Checklist
Supporting documentation on file establishes that recipient:
19.
Meets EWC program age, income, and insurance criteria.
[ > 40 years of age for Breast Services or > 21 years of age for Cervical Services]
[ < 200% Federal Poverty Level; Payor of Last Resort: Unmet Share Of Cost, Unmet deductible, Exhausted Family PACT, No Medicare Part B]
20.
Signed EWC consent form
S
21.
Breast and Cervical Cancer Treatment Program—See page 2 for additional referral requirements
I have determined that this woman is eligible for EWC services*.
For recipients who answered Yes to ***Item 18a or 18b above, I have notified clinician to assess smoking status and refer to
tobacco cessation resources.
Primary Care Provider Staff Certifying Signature
Date Certified
*Eligibility determination policies and information are located in the Can Detect Portion of the Medi-Cal Manual.
DHCS 8699 (Rev 1/13)
Page 1 of 3
Complete all fields. Place original in patient chart.
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