ASSURED ACCESS by tlp18619


									                                   ASSURED ACCESS
                                  ELIGIBILITY FORM
Hennepin County Human Services Department      330 S. 12th St. Ste. 3700
Front Door Services                            Minneapolis, MN 55404
Office of Multi-Cultural Services         612-348-6141 FAX (612) 466-9688

Before you complete the Assured Access application we would like to inform you that the information you provide is generally private. You are not
required to answer the questions asked, but we may not be able to help you or determine eligibility if you do not provide us with some information. The
information you provide may be shared with other staff in the statewide welfare system whose jobs require accessing this information and with staff in
this or other agencies as provided by law. The information you give us will be used to determine eligibility for Assured Access. A complete explanation
of our privacy practices can be found at:

         PLEASE PRINT.
        Client #
        Last name                                        First name                             MI          Today’s date

        Date of Birth                      Sex                              Are you employed?               Requesting Assured
        _____/____/____                    □ Male                           □ YES                           Access?
        month day year                     □ Female                         □ NO                            □ YES □ NO
        Home Address (Street)                              Apt #            City                                    Zip Code

        Does this person have Medical              Is insurance offered at work?
        Insurance?                                 □ YES      □ NO
        □ YES           □ NO
        Telephone Number                           Check your race (optional)                                           Preferred spoken
        (____) _____-______                        □ African        □ Black/African American                            language?
                                                   □ American Indian/Aleutian, Eskimo
        Are you a US Citizen?                      □ Asian, Pacific Islander □ Hispanic/Latino
        (optional) □ YES      □ NO                 □ White                □ Other

         Is there a second adult in the household?
         □ Yes–fill out information below                                     □ No–go to next section
        Last name                                            First name                              MI          □ Male
                                                                                                                 □ Female

        Relationship: Spouse                             Parent of Minor Child                    Other
        Is this person employed?                Does this person have Medical        Is insurance offered at work?
        □ YES     □ NO                          Insurance?                           □ YES      □ NO
                                                □ YES           □ NO
        Date of Birth                           Check your race (optional)                     Requesting Assured
        _____/____/____                         □ African      □ Black/African American        Access?
        month day year                          □ American Indian/Aleutian, Eskimo             □ YES

        Is this person a US Citizen?    □ Asian, Pacific Islander □ Hispanic/Latino        □ NO
        (optional)                      □ White                □ Other
        □ YES     □ NO

        CHILDREN IN YOUR HOUSEHOLD                                US Citizen    Date of       Requesting
        Under 18 years old and living in the home with you.                     Birth         Assured Access
                                                                  (Optional)                  for this child?
        Last Name                      First Name                 Yes    No                      Yes        No

                                         INCOME INFORMATION
    INCOME MAY NEED TO BE VERIFIED                  Amount           Who Got it            Date Received
     Employment           □ YES □ NO                 $
        Self-Employment                □ YES □ NO    $
        RSDI (Social Security)         □ YES □ NO    $
        SSI (Supplemental              □ YES □ NO    $
        Security Income)
        VA (Veterans’ Benefits)        □ YES □ NO   $
        Unemployment Insurance         □ YES □ NO   $
        Workers’ Compensation          □ YES □ NO   $
        Retirement Benefits            □ YES □ NO   $
        Child or Spousal Support       □ YES □ NO   $
        Other                          □ YES □ NO   $

Is anyone in your household pregnant?  Yes                   No
Is anyone in your household:            □ under 21?              □ Over 65?
       □ Have children or responsibility for minor relatives under 18?
Do you have an ongoing need to see a doctor for:
       □ Chronic condition such as asthma, diabetes, high blood pressure, cancer, tuberculosis, migraine
         headaches, ADHD, HIV/AIDs, etc.
       □ Any other condition that you might need to see a doctor for on a regular basis
Have you seen a doctor, dentist, or filled a prescription in the past 3 months for:
       □ Any illness or injury that caused you pain      □ Abscessed tooth
       □ Emergency room visit                            □ Ear Infection
       □ Heart attack                                            □ Broken bones
       □ Any other illness or injury that was unexpected

By typing my name below, I declare that I have examined this application and, to the best of my knowledge and belief, it
is a true and correct statement of every material point.


                                        FOR OFFICE USE ONLY:
        PENDING: _________________________________________________ Date: _________________________

        Response: _____________________________________ PROCESS COMPLETED: ____________________


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