Form F-01187 - Wisconsin Hemophilia Home Care Program Financial Need Statement - 2016 Page 3
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5WHHCP FINANCIAL NEED STATEMENT
Page 3 of 5
F-01187
SECTION 5. INSURANCE INFORMATION
19. In the last two years, have you had or do you currently have private, group, the Wisconsin Health
Yes
No
Insurance Risk Sharing Plan (HIRSP), or other health insurance coverage for medical expenses?
(Do not include Medicare, Medicaid, BadgerCare Plus, or SeniorCare information here.)
If yes, complete the following information. If you have more than one insurance company, list the
second company under Insurance 2. Attach additional information if needed for current and past
insurance for the last two years.
Insurance 1
Insurance 2
a. Name – Insurance Company
b. Telephone Number
a. Name – Insurance Company
b. Telephone Number
c. Name – Policy Holder
d. Relationship of Policy Holder
c. Name – Policy Holder
d. Relationship of Policy Holder
e. Policy Number
f. Group Policy Number
e. Policy Number
f. Group Policy Number
g. Coverage Begin Date
h. Coverage Termination Date
g. Coverage Begin Date
h. Coverage Termination Date
Indicate whether this insurance covers the services listed
Indicate whether this insurance covers the services listed
below.
below.
i. Inpatient Hospital Service
Yes
No
i. Inpatient Hospital Service
Yes
No
j. Outpatient Hospital Service
Yes
No
j. Outpatient Hospital Service
Yes
No
k. Physician Services
Yes
No
k. Physician Services
Yes
No
l. Radiology Services
Yes
No
l. Radiology Services
Yes
No
m. Laboratory Services
Yes
No
m. Laboratory Services
Yes
No
n. Hemophilia Home Care Products and
Yes
No
n. Hemophilia Home Care Products and
Yes
No
Supplies
Supplies
o. Prescription Drugs
Yes
No
o. Prescription Drugs
Yes
No
SECTION 6. FINANCIAL INFORMATION
20. Indicate the number of dependent family members; include yourself if you are a dependent family member.
21. Indicate your current total income by completing items a.
Month
Year
Year
through m. either by monthly OR annual totals.
Average Monthly Totals
Annual Totals
$
$
a. Gross wages, salaries, tips, etc.
$
$
b. Net income from non-farm self-employment
$
$
c. Net income from farm self-employment
$
$
d. Social Security and/or Supplemental Security benefits
$
$
e. Dividends and interest income
$
$
f. Total of estate or trust income, net rental income, and royalties
$
$
g. Cash public benefits (e.g., W-2 payments)
$
$
h. Pensions, annuities, and/or Veterans Pension
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