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General

Client Info

Where did you hear about the SFL and/or HCC:

Specify

* Last Name

* First Name

MI

Maiden Name

Please list other names you may have used

* What is your housing situation today?

Home Address

Address

City

State

Zip Code

-

County

Mailing Address Copy Home Address

Address

City

State

Zip Code

-

County

Contact

* Daytime Phone

Primary Phone Type

Other Phone

Alt. Phone Type

* Email

Client agrees to accept emails from the SFL Program

Alt. Language

Age & Ethnicity

* Date of Birth

Age:

* Sex

SSN

Primary Language

Other Language:

Served in Armed Forces

* U.S. Citizen

* If Not, Has Legal Documentation

Race

Hispanic/Latino

Do you identify as Haitian?

1. Highest Level of Education

* Household Members:Tell us who is in your family. A household consists of you (the client), your spouse, and any children 18 years of age and younger within your legal guardianship, including unborn children.

Number of people in your household:

Add Household Member

* Would you like someone from the Maternal Child Health program at Public Health to contact you about programs you may be eligible for?

Yes No

By selecting yes I authorize the Division of Public Health Screening for Life/HCC program to provide the Maternal Child Health Program with my contact information and any other information that is needed to determine program eligibility.

Eligibility

3. This year does your health care pay for (check all that apply)?

Pap Smears

Mammograms

Colorectal Exams

Prostate Screenings

Lung Cancer Screening (LDCT)

Access

10. Was there a time during the last 6 months when you needed to see a doctor, but could not because of any of the following reasons? Please read and check all that apply.

Cost

Inconvenient Hours

Transportation

Language Barrier

Provider Supply

None

11. Do you have a primary care doctor or healthcare provider? (A primary care doctor is a doctor who will see you for a checkup and sick visit).

11a. Who is your provider?

11b. Where is your provider located?

12. If you are sick or need medical advice, where do you go?

13. What types of assistance, if any, do you need in making or keeping medical appointments?

Child care/Eldercare

Transportation

Language

None

Other

Health

14. In the past 6 months, have you had any health problems?

Add New Health Problem

15. Have you or any member of your family had cancer?

* 16. Currently, do you smoke cigarettes, cigars, pipes or use other tobacco products?

* Would you like to be referred to DE Quitline?

Yes No

17. Have you smoked cigarettes in the last 15 years?

18. Do you smoke cigarettes?

19. On average how many packs of cigarettes do/did you smoke per day?

packs

20. How long have you been smoking cigarettes, or how long did you smoke cigarettes?

years

21. Have you had a CT scan of your lungs within the last 12 months?

* 22. Do you live in a house with a basement below ground level?

Would you like to be referred to Delaware Healthy Homes?

Yes No

* 23. Has a doctor, nurse or other health professional ever told you that you have diabetes?

* 24. Has a doctor, nurse or other health professional ever told you that you have high blood pressure?

* 25. Has a doctor, nurse or other health professional ever told you that your cholesterol is high?

26. Women only: Are you pregnant?

27. Women only: Do you plan to become pregnant in the next year?

Women only: Would you like someone from the Maternal Child Health program at Public Health to contact you about programs you may be eligible for?

Yes No

By selecting yes I authorize the Division of Public Health Screening for Life/HCC program to provide the Maternal Child Health Program with my contact information and any other information that is needed to determine program eligibility.

28. Women only: Do you still have your cervix?

28a. If no, was it removed due to cervical cancer or pre-cervical cancer?

29. Do you have a disability?

* 30. In the past year have you experienced lack of food for yourself and your family?

* 30a. If yes – Would you like to be referred to free resources for food?

* 31. Is lack of daytime transportation a barrier to attending your cancer screening appointments?

* 32. Do you have children in your home?

* 32a. If yes – Do you have appropriate child care available to attend your medical appointments?

* 32b. If no – Would you like to be referred to resources for child care assistance?

32c. If yes – Which type(s) of childcare are you using? (use control+click to select or deselect multiple items)

32d. If yes – Have you had any of these child-care related problems during the past year? (use control+click to select or deselect multiple items)

* 33. Do you have adequate access to home cleaning supplies?

* 33a. If no – Would you like to be referred to free resources for cleaning supplies?

* 34. Women Only: Have you ever received a pelvic exam?

* If yes: What was the date of your most recent pelvic exam (MM/YYYY):

* 35. Women Only: Have you ever received a Pap test?

* If yes: What was the date of your most recent Pap test (MM/YYYY):

* 36. Women Only: Have you ever received a HPV test?

* If yes: What was the date of your most recent HPV test (MM/YYYY):

* 37. Women Only: Have you ever received a mammogram?

* If yes: What was the date of your most recent mammogram (MM/YYYY):

* 38. Do you use any of the following types of computer: Desktop/Laptop, Smartphone, Tablet?

* 39. Do you or any member of this household have access to the internet?

Files

Proof of Name and Date of Birth

Document must contain proof of full legal name and date of birth (i.e. Birth certification, DE driver’s license, State identification, Passport, Permanent Resident card, Matricula Consular Card, Employment Authorization card)
If name has been changed, please provide proof of legal name change

Add File

Proof of Ineligibility or Exemption from the Health Insurance Marketplace

HCC Only
Completed DPH Client Self-attestation form may be acceptable (included in your enrollment application packet)
Download Forms:
Self-Attestation Form (English)
Self-Attestation Form (Spanish)
Self-Attestation Form (Haitian)

Add File

Proof of Health Insurance, if applicable

If you indicated you have health insurance on the enrollment application, please provide a copy of your health insurance card, indicating deductible amount and covered benefits

Add File

Proof of Household Income

A Household consists of you (the client), your spouse, and any children under the age of 18 within your legal guardianship. All others not meeting this description should NOT be included in your application.
(provide a copy of ALL that apply)
If you and/or spouse are employed, provide proof of last 4 weeks’ income (paystubs for the last 30 days with gross amount and deductions)
If unable to provide paystubs for you and/or spouse, provide an statement from the employer, indicating how many hours you work per week and your hourly rate
If self-employed, provide your most recent completed tax return with all schedules
If you receive Unemployment, Social Security Benefits , Temporary Assistance for Needy Families (TANF), Alimony, Worker’s Compensation, Child Support, Pension or Disability, provide the notice/award letter, listing the income awarded and/or received
If you have no income, provide a letter/statement of support from the individual who is providing financial support
Download Forms:
Employment Verification Form for Applicant (English)
Employment Verification Form for Applicant (Spanish)
Employment Verification Form for Applicant (Haitian)

Employment Verification Form for Spouse/Parent/Guardian (English)
Employment Verification Form for Spouse/Parent/Guardian (Spanish)
Employment Verification Form for Spouse/Parent/Guardian (Haitian)

Financial Support Verification Form (English)
Financial Support Verification Form (Spanish)
Financial Support Verification Form (Haitian)

Add File

Proof of State of Delaware Residency – Home Address

(provide a copy of 1 of the following)
Delaware Driver’s License or State Identification card
Utility invoice with current home address (Note: Cable and phone bills are not considered utility invoices)
Current Lease and/or Rental Agreement
If unable to provide the above documents, provide a statement verifying your physical address and your intent to reside in Delaware
Download Forms:
Delaware Residency Verification Form (English)
Delaware Residency Verification Form (Spanish)
Delaware Residency Verification Form (Haitian)

Add File

Medical Records

Add File

Billing Records

Add File

Other Files

Add File

Agreement and Authorization to Release Information

I have provided, and will continue to provide, true and accurate information.

I give my consent for you to access the state information system to determine my eligibility for medical assistance benefits, and to share and discuss my information with my health care provider(s) to ensure that I receive the appropriate screenings and/or follow-up care. I authorize you to give my medical and other information to others for the purpose of survey, study, or research as long as personal identifying information about me is not made public.

I give my consent for you to contact me to discuss barriers to care so that referral options and patient navigation services can be discussed and provided to clients who are both agreeable and eligible to receive these services.

First Name:
Middle Name:
Last Name:
Maiden Name:
Relationship:
Birth Date:
Gender:
SSN:
Race:
Additional Race:
Hispanic:
Served in Arm Forces:
US Citizen:
Legal:
Insured:
Save Household Member

Family Member:
Specify Other Family Member:
Mother's Or Father's Side:
Diagnosis Age:
Onset Date:
Cancer Type:
Specify Other Cancer Type:
Save Family Member Diagnosis

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General

Client Info

Home Address

Mailing Address content_copy Copy Home Address

Contact

Age & Ethnicity

Eligibility

Access

Health

Files

Agreement and Authorization to Release Information

Mailing Address Copy Home Address