Financial Eligibility Application Nc Dhhs 3014 Adap printable pdf download

1. Last Name

First Name

FINANCIAL ELIGIBILITY APPLICATION

FOR POMCS USE ONLY

Purchase of Medical Care Services

DHHS – Controller's Office

2. Patient SS #

1904 Mail Service Center • Raleigh, NC 27699-1904

—

3. Date of

4. Sex

1. Male

11. Program

12. Case Number

Birth

Month

Day

Year

2. Female

5. Race

1. White

2. Black

3. American Indian

4. Asian

13. NC Resident ! Yes ! No If yes, select one of the following:

5. Native Hawaiian/Other Pacific Islander

6. Unknown

(Applicants to ADAP need only answer Y/N)

! 1. US citizen who lives in NC and intends to make NC his permanent home

Ethnicity: Hispanic or Latino Origin?

Yes

Unknown

! 2. Non citizen who has applied for US citizenship. INS documentation required

6. Preferred Language ______ Select from the list on the back of this form

! 3. Non citizen who has a permanent resident visa or has applied for one

(INS documentation required)

7. County of Residence

! 4. Migrant farmworker according to the federal definition

Migrant (Farmworker) Health Program Eligibility Application (DHHS 3753) required

8. Address

Street or RFD

Note: Migrant farmworker status meets the residency requirement for all POMCS programs

14. Countable Family Members

15. Earliest Requested Date of Program

9. City

State

Zip Code

Coverage

Number of Adults

________

Number of Children ________

10. Telephone

Total Number

________

Number: Home

Work

Month

Day

Year

INCOME FORMULAS: Regular (R) – Continuously employed wage earners list income for the 12 months before the date of application or the requested date of coverage, whichever is earlier.

Unemployment (U) – Wage earners unemployed at the time of application or for 30 consecutive days during the previous 12 months list income for 6 months before and after the date of

application or the requested date of coverage, whichever is earlier. Cancer Program and ADAP are based on gross income. Must report Gross and Net Income for ADAP.

16. Complete for All Countable Family Members

Income

List all Employers or Sources of

Income After Tax

Relationship

Formula

Income/Reason for None

Dates

(Not for ADAP or

Name

to Patient

(R or U)

for 12 Month Period

From

Gross Income

Cancer Program)

17. Explanations: Dates unemployed; means of support if income is low; etc.

18. Annual Gross Income (Stop here for

Cancer Program only. For ADAP include

Annual Gross Income and Annual Net Income.)

Federal, State & Soc. Sec. Tax

Income After Taxes

Total Income After Taxes

$_____________

(Sum of Both Lines)

19. Eligibility for Other Programs

Medicaid ID # ___________________

Medical expenses paid or incurred

Medicare: ! Part A ! Part B ! Part D

Medicare # ___________________

during past 12 months not covered

by a third party nor requested for

! Yes ! No

Social Security LIS Application

program coverage

$_____________

VA Benefits: Are you a veteran? ! Yes ! No

Other deductions:

Did you actively serve in any branch of the military for over 180 days? ! Yes ! No

(Specify)________________________

$____________

! Yes ! No

Did you receive an honorable or general discharge?

Total Deductions

$_____________

20. Was patient's problem caused by an accident? ! Yes ! No

If yes, liability compensation is ! Pending ! Awarded ! Ruled Out

Annual Net Income

$_____________

(All Other Programs)

Give attorney's name, address and phone number in block #17.

21. HEALTH INSURANCE COVERAGE Provide complete insurance information and copies of insurance cards for all countable family members.

Company________________________________________________________________

Company _________________________________________________________________

Policy No. _______________________________________________________________

Policy No. ________________________________________________________________

Claims Address __________________________________________________________

Claims Address ____________________________________________________________

________________________________________ Telephone ______________________

_________________________________________Telephone _______________________

Policyholder _____________________________________________________________

Policyholder ______________________________________________________________

Is patient covered? ! Yes ! No

Is this an HMO? ! Yes ! No

Is patient covered? ! Yes ! No

Is this an HMO? ! Yes ! No

22. I hereby certify that I have read or the interviewer has read to me the terms and conditions contained on the back of this form and that I agree to comply with them. I also certify that I

have been provided opportunity to ask the interviewer questions about these terms and conditions and that I understand the answers I was given.

___________________________________________________________ ______________________________________________________

___________________________

Applicant's Signature

Relationship to patient

Date

23. I certify that I have explained the terms and conditions contained on the back of this form to the applicant and have witnessed his signature.

___________________________________________________________ ______________________________________________________

___________________________

Type or Print Interviewer's Name

Agency Name

Date