Health Coverage Analysis

If you complete this form and submit it, Cover the Uninsured Week and the S.W. Ohio Covering Kids and Families Coalition 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. Fields marked in red are required.

Your Name
First Name:	Middle Name:	Last Name:

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

Contact Information
Phone: - -	Email:

Health Coverage Analysis

For everyone 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

Where did you find out about this website?

Friend	Radio Ad	Internet	Postcard

Newspaper	Television	Other:

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Health Coverage Analysis

Your Name

Address

Contact Information

Health Coverage Analysis