Form Dhs-2 - Application Forassistance - Rhode Island Department Of Human Services Page 29
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DHS-2 Rev. 10-14
Page 25
Is there a child or adult applying for Medicaid covered by a
37
Yes
health insurance, Long-Term Care insurance, dental insurance
No
program or HMO other than Medicare, Medicaid, RIteCare or
RIteShare?
EXAMPLES:
BlueCross/Blue Shield
United HealthCare of New England
Delta Dental
BlueChip
Neighborhood Health Plan of RI
BCBS Dental
If yes, complete the boxes below.
I N S U
Policy Holder’s name
Middle
Health and/ or Dental
Type of
Family
[ ]
If premium paid by you
Insurance Name
Coverage
Individual [ ]
Amount/How Often
Last Name
First Name
Initial
$
per
Policy Number
Group Number
Is insurance
If yes, name of employer providing
Code
Type
Req
provided by employer?
insurance:
Yes [ ] No [ ]
Please list below person(s) covered by this policy.
Individual’s Policy Number
Last Name
First Name
Middle Initial
Relation
Begin Date
End Date
___/___/___ ___/___/___
___/___/___ ___/___/___
___/___/___ ___/___/___
___/___/___ ___/___/___
Policy Holder’s name
Middle
Health and/ or Dental
Type of
Family
[ ]
If premium paid by you
Insurance Name
Coverage
Individual [ ]
Amount/How Often
Last Name
First Name
Initial
$
per
Policy Number
Group Number
Is insurance
Code
Type
Req
If yes, name of employer providing
provided by employer?
insurance:
Yes [ ] No [ ]
Please list below person(s) covered by this policy.
Individual’s Policy Number
Last Name
First Name
Middle Initial
Relation
Begin Date
End Date
___/___/___ ___/___/___
___/___/___ ___/___/___
___/___/___ ___/___/___
___/___/___ ___/___/___
Yes
Do you, your spouse, or anyone in the household have any unpaid
38
No
medical bills?
If yes, did you have any medical coverage when the bills were incurred? Yes
No
If you have any unpaid medical bills, complete the boxes below about each person who received medical treatment.
M E D X
Last Name
First Name
Middle Initial
Date of Service
Who do you owe?
Amount Owed
/
/
$
/
/
$
/
/
$
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