Palco Enrollment Form English Project Access Lancaster County Page 2
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415. Do you have children under 21 living in the home?
_____ Yes _____No
If no, are your resources (cash, bank accounts, IRA’s, etc.) less than $2000?
_____ Yes _____No
16. Are you or anyone who lives with you pregnant?
_____ Yes _____No
17. Do you require health-sustaining medications?
_____ Yes _____No
18. Do you have any unpaid medical bills from the last 3 months?
_____ Yes _____No
If yes, what is the approximate dollar amount? $___________
19. Who is your primary care physician? Practice and site _______________________________________________
_____________________________________________________________________________________________
20. Have you lived in Lancaster County for more than 3 months?
_____ Yes _____No
21. Race/Ethnicity: (optional)
African/American ______ Asian/PacificIslander ______ Caucasian ______ Hispanic ______ Other ______
22. What language do you prefer? __________________________________________________________________
23. List barriers to appointments with providers ( i.e. outstanding bills, termination, lack of transportation, no
English spoken, etc) ___________________________________________________________________________
_____________________________________________________________________________________________
24. Are you employed? Yes_____ No_____ If yes, where? _____________________________________________
If no, date of last employment __________________________________________________________________
25. Does your work place offer health Insurance?
_____ Yes _____No
If yes, how much would it cost per month? $________
26. Translator needed?
_____ Yes _____No
27. Transportation needed?
_____ Yes _____No
Income: List amount of monthly gross income (before taxes and deductions):
Salary/
Social
Disability
Unemployment
Worker’s
Pension/
Self-
Child
Other
Wages
Security/
Comp
Retirement
employment
Support/
Income
SSI
Alimony
$
$
$
$
$
$
$
$
$
Self
$
$
$
$
$
$
$
$
$
Spouse
$
$
$
$
$
$
$
$
$
Child
(under 18)
$
$
$
$
$
$
$
$
$
Child
(under 18)
$
$
$
$
$
$
$
$
$
Other
Total Gross Income $________
Total in Checking/Savings $_________
If no income, please explain how your basic needs are being met _________________________________
_________________________________________________________________________________________
_________________________________________________________________________________________
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Parent category: Legal