Health Coverage Analysis

Health Coverage Analysis

If you complete this form and submit it,  the Covering Kids and Families Project can tell you whether you are likely to qualify for some kind of free health or low cost public health coverage.  We will get back in touch with you to let you know and we can help you apply if it appears that you are eligible.

Your Name

First Name (required)
Middle Name
Last Name (required)

Address

Street:
City:
County:
State:
Zip Code:
-

Contact Information

Phone (Required):
- -
Email:
How Many Children In Houshold?

Health Coverage Analysis

For everyone (including children) in your household list Name, Birth Date, Source of Income, Amount of Income, How often income received.

Is anyone in your household pregnant?
 Yes No

If yes, who?

Does anyone in your household have a medical condition that prevents them from working full time?
 Yes No

If yes, who and what condition?

Does anyone in your household have any medical coverage now?

 Yes No

If so, who and from what source (e.g. insurance company, Medicaid, Medicare)?

Does anyone in your household have outstanding medical bills?

 Yes No

If yes, list outstanding medical bills.

Household Member Medical Provider Date of Service Amount of Bill

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