Medical Renewal Form Page 6
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9Case name:
Case number:
Date of request:
4. If any income has recently changed or will be changing in the next month or two, please
let us know why. If your income is going to be less, please let us know what you expect your
gross income (before taxes and deductions) to be next month.
____________________________________________________________________________
____________________________________________________________________________
Tell us about your household’s resources
1. Tell us about the following resources that belong to anyone in your home who is related to
you or your children (including expected children):
• checking accounts
• stocks and bonds
• cash
• savings accounts
• certificates of deposit
• vehicles
• property (land and buildings; do not include the home you live in)
Kind of resource
How much
How much is
This resource
is it worth?
still owed?
belongs to:
(for vehicles include model year and make)
1
resource:
st
2
resource:
nd
3
resource:
rd
4
resource:
th
Please use another sheet of paper if you need to write about more resources.
Health information
1. Does anyone who you want medical coverage for have a disability, kidney disorder or a
condition that, without treatment, would be life-threatening or cause permanent loss of
function or disability?
Yes No
If yes, who? _________________________________________________________________
2. Does anyone 19 years or older who you want medical coverage for have a
kidney disorder or a serious disability that prevents them from working?
Yes No
If yes, tell us who and explain. ___________________________________________________
____________________________________________________________________________
3. Our records show the following people have private health insurance:
DOB:
,
DOB:
DOB:
,
DOB:
DOB:
,
DOB:
Has this changed? Yes
No
Does anyone else have private health insurance?
Yes
No
If yes, who? _______________________________________________________________
If you answered yes to either question, you will need to send copies of the front and back of all
insurance cards and complete a MSC 0415H. You can get the MSC 0415H at your local office or
at:
?
?
Need help?
Please call your worker. The phone number is at the top of the first page.
Page 6
OHA 0945 (06/12)
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