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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

Home Address

Address
City
State
Zip Code
County

Mailing Address content_copy Copy Home Address

Address
City
State
Zip Code
County

Contact

Daytime Phone
Other Phone
Email

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:
First NameLast NameMIDate of birthRelationship 
  • 1
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Would you like someone from the Maternal Child Health program at Public Health to contact you about programs you may be eligible for?

Eligibility

2. What Kind of health care coverage do you have (check all that apply)?
 
3. This year does your health care pay for (check all that apply)?
4. Have you met your deductible?

Specify amount of deductible:
5. Have there been any changes in your health care coverage in the past 6 months?

Please Specify:
6. How long has it been since you had health care coverage?
7. What is the main reason your are without health care coverage?
8. What is your household income before deductions (gross income)? Include your income and your spouse if married, or parents if under the age of 18.
9. Are You (please check all that apply)

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.
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).
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?

Health

14. In the past 6 months, have you had any health problems?
15. Have you or any member of your family had cancer?
16. Currently, do you smoke cigarettes, cigars, pipes or use other tobacco products?
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?
23. Has a doctor, nurse or other health professional ever told you that your have diabetes?
24. Has a doctor, nurse or other health professional ever told you that your 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?
28. Women only: Do you still have your cervix?
29. Do you have a disability?

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
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)
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
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
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
Medical Records
Billing Records
Other Files

Agreement and Authorization to Release Information