Healthcare Application For The Elderly And Disabled Page 3
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10SFN 958 (3-2016)
Page 3 of 10
Tell Us About You
First Name
Last Name
Middle Initial
Suffix
Address Where You Live
City
State
ZIP Code
Mailing Address (if different)
Home Telephone Number
Work or Message Number
Cell Phone Number
Directions to Home (if rural)
*** If you are applying for Health Care Coverage (Medicaid or CHIP) and you have entered your residential and mailing
address as 'General Delivery', or 'Homeless', or have left it blank, your mail will be sent to the local county social service
office. You will need to arrange to pick up your mail at the local county social service office on a weekly basis. If you do not
pick up your mail for three (3) weeks, your case may be closed due to lack of contact. ***
Power of Attorney or Family Contact Person
First Name
Last Name
Relationship
Mailing Address Where You Want Notices Sent
Home Telephone Number
Work or Message Number
Cell Phone Number
Would You Like to Receive Text and E-mail Notification
By opting to receive text message or e-mail notifications, you agree to the following:
A text message or e-mail notification will be sent to the cell phone number or e-mail address you entered when a review or full
application is needed to determine eligibility or continued eligibility for the program(s) you are enrolled in.
Cell phone carrier text message rates may apply and DHS will not be liable for any text message charges.
You are responsible for notifying your case worker of any changes to your e-mail address, cell phone carrier or cell phone
number, or if your cell phone is lost or stolen.
Note that unencrypted e-mail and text messaging is NOT a secure form of communication. There is some risk that any
Protected Health Information (PHI) and other confidential information that may be contained in such e-mail or text messages
may be misdirected, disclosed to, or intercepted by, unauthorized third parties. I consent and accept the risk in transmitting
PHI and other confidential information via unencrypted e-mail or text messaging.
If yes, list name of cell phone provider:
Would you like to receive text message notifications?
Yes
No
If yes, list e-mail address:
Would you like to receive e-mail notifications?
Yes
No
Signature
Date
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Parent category: Medical