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Eligibility Questionnaire

Program Evaluation Questions

*Are you a U.S. Citizen or Resident? (more than 5 years)

YesNo

*Are you a legal immigrant?

YesNo

*Are you Male or Female?

MaleFemale

*Do you have any of the following?

MedicaidMedicareCHIPSPrivate InsuranceNone of the Above

*Are you or anyone in your household working or receiving other sources of income? (Medicaid, Social Security, Unemployment, etc)

YesNo

*What is your monthly gross (before taxes) income?

*Is any of your income from the following sources? Check all that apply.

Medicaid-TANFSocial SecuritySocial Security DisabilitySocial Security RetirementNone of the Above

*How many people live in your household?

*Do you have any children under the age of 18?

YesNo

*Do your children have any of the following?

MedicaidChipsSS DisabilityPrivate InsuranceOther InsuranceNone of the Above

*Do you have a physical condition/disability that causes you to work fewer hours or inhibits you from working?

YesNo

*Have you applied for social security / disability?

YesNo

*Do you have Medicare Part A, Part B, and/or Part D and find yourself unable to pay the co-pays and/or premiums?

YesNo

*Are you on disability and are in the 24 month waiting period for Medicare?

YesNo

Contact Information

Please enter your contact information below so one of our Community Health Specialsts can get in touch with you.

*Name

*Phone Number

Eligibility Questionnaire - Gulfcoasthc
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