Form Sfn 958 - Health Care Application For The Elderly And Disabled Page 9
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10SFN 958 (4-2017)
Page 9 of 10
Tell Us About Your Health Insurance Coverage
List household members who have health insurance:
Type of
Policy Holder
Health Insurance
Coverage
Effective
Policy
Group
Monthly
Name and
Name and
Persons Covered
Date
Number
Number
Use Codes
Address
Address
Premium
Below
List all that apply
I - HMO Insurance
A - Hospital
E - Vision
N -Prescription Drug Insurance
J - Court Ordered
B - Doctor
F - Nursing Home
P - Workers Compensation or Accident
K - Medicare Part A
C - Major Medical/Lab/X-Ray
G - Cancer
V - Veterans Administration
L - Medicare Part B
D - Dental
H - Champus/Tricare
W - Medicare Part D
M - Medicare Supplement/Advantage
If yes, who?
Does anyone outside the household pay the premium?
Yes
No
Yes
No
If yes, explain:
Do household members expect changes in health insurance coverage?
Long Term Care Insurance
Does any household member have a long-term care insurance policy that has paid out benefits
Yes
No
for long-term care serivces (nursing care, basic care, or assisted living)?
If yes, who?
Amount the Policy Paid in Benefits:
This information may allow you to protect additional assets.
Tell Us if Someone Else May Help With Your Medical Costs
If yes, explain:
Does anyone help pay your medical costs?
Yes
No
Do household members have medical problems due to an accident?
If yes, complete below:
Yes
No
Type of Accident:
Date of Accident:
Do household members have a pending legal action from which they may receive money
Yes
No
or medical benefits (including inheritance?)
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Parent category: Medical