Medical Renewal Form Page 3
ADVERTISEMENT
1
2
3
4
5
6
7
8
9Case name:
Case number:
Date of request:
4. Pregnancy. Please tell us about anyone in your home who is pregnant (including yourself or
anyone related to you or your children).
You must send proof. Please send a copy of a letter from a doctor or clinic saying this
person is pregnant.
Due date
Does the baby’s father
Name
(month, day, year)
live in your home?
st
1
person:
yes no If yes, what is his name?
nd
2
person:
yes no If yes, what is his name?
5. Please tell us about anyone in your home (related to you or your children and 16 years or older)
who is in high school, college or technical or vocational school. We will contact you if we
need proof.
Does the school consider this
Name
School name
student full or part time?
st
1
person:
Full time Part time
nd
2
person:
Full time Part time
rd
3
person:
Full time Part time
6. Absent parents. Answer if you are applying for any child under age 19 (including expected
children) whose parents are absent. Absent parents are parents who do not live in the
household, including parents who are in jail.
Absent parent
Name (first, middle initial, last):
This is my: spouse or ex-spouse
child
partner or ex-partner
step child
other: _________________________________
Date of birth: (month, day, year):
Sex: Female
Social Security number (if you know it):
Male
Address:
City:
State:
ZIP code:
Date this parent stopped living with child (month, day, year):
Phone:
Hours each week this parent spends with
List this parent’s children
the child in the child’s home:
(if you have included those
children on this application).
If this is an absent father, has paternity been legally established?
Yes
No
I don’t know
Can the child or children get health insurance through this parent?
Yes
No
I don’t know
Do you think this parent might hurt you or the child if we try to find
out about paternity or health insurance?
Yes
No
*Use another sheet of paper if you need to write about more absent parents.
?
?
Need help?
Please call your worker. The phone number is at the top of the first page.
Page 3
OHA 0945 (06/12)
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business