Pe Pregnancy Patient Information Form - Kentucky
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1PRESUMPTIVE ELIGIBILITY PREGNANCY
Patient information form
How many family members does this person have? ___________________
When calculating family size, include expectant mother, unborn child/children, dependent
Social Security Number _____________________
This person does not have a social security number
children living in the home and spouse. If expectant mother is living with parents and under age
19 count parents, step-parent and siblings under 19 in the household size.
Name: __________________________________________________________________________________
Last Name
First Name
Middle Initial
Expected due date (mm/dd/yyyy) ____________________________________________
Whe
Date of Birth: __________________________
Age ______________
Female
FAMILY INCOME
Income Type*
How Much?
How Often
Marital Status (check one):
Single-Never Married
Divorced
Separated
Legally Separated
Family Member’s Name
**
1
Widowed
Living Together Partner
Married Living Together
Married Living Apart
2
Has this person received Presumptive Eligibility benefits for this pregnancy?
Yes
No
3
Is this person a resident of Kentucky?
Yes
No
4
Is this person a US Citizen?
Yes
No
TOTAL MONTHLY
Race: ___________________ Nationality: __________________________
INCOME:
Count income of expectant mother and spouse. Parents’ income (if expectant mother is living
Is this person of Hispanic, Latino, or Spanish origin?
Yes
No
with parents and claimed as a tax dependent). Include gross wages (before taxes), and other
Ethnicity: ________________________
sources of income such as social security, pensions, alimony, cash gifts and annuities.
Do not count child support or SSI (Supplemental Security Income).
Do not count income of dependent children (whether or not they live in the home with expectant
Preferred Written Language
English
Spanish
mother).
Would this person like to be referred for WIC?
Yes
No
OTHER INSURANCE
Does this person currently have insurance that covers doctors, office visits, and hospitalization?
Is this person currently incarcerated?
Yes
No
Yes
No
If yes, when did this person enter prison? (mm/dd/yyyy) ___________________
If “Yes”
What is the name of this plan ________________________________
What date should benefits begin? _____________________________
Name of Insurance Co.
Policy No.
Group No.
___________________________________________________________________________________
Address:
________________________________________________________________
Preferred MCO:
Street Address
Apt/Building Number
Anthem Blue Cross/Blue Shield
CoventryCares
Humana CareSource
Passport Health Plan
WellCare
________________________________________________________________
Primary Care Physician ____________________________________________________
City
State
Zip Code
I certify, under penalty of perjury, the information provided by me in this statement is correct and
_____________________
true to the best of my knowledge. I understand that anyone who gives false information in order
County
to receive benefits, or lets someone else use their PE card or abuses PE benefits is subject to
criminal action under federal law, state law or both or may be liable for repaying in cash the value
Telephone Number(s):
of the benefits received.
__________________________________________________________________________________________
______________________________________
_______________
Home/Cell Telephone Number
Work Telephone Number
other
Patient Signature
Date Signed
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