INTKE/ELIGIBILITY FORM
INTAKE AND ELIGIBILITY FORM
This form is used by staff (who may or may not be case managers) to obtain and document required information to determine a person’s eligibility to receive HIV/AIDS medical and support services under the Mecklenburg County Transitional Grant Area (TGA).
| |
|Date of Initial Contact: / / Date Intake/Eligibility Initiated: / / |
|_________________________________ _________________ |
|Case Manager Signature Date Intake Completed |
| a. Personal/Contact Information |
|NAME Soc.Sec.No. |
|Address City/Township |
|County State Zip Code |
|Referred By Phone |
|Phone (H) ( ) (W) ( ) (Emg) ( ) |
|Date of Birth Race Language |
|Client provided proof of residency: Y N |
|Client Preference for Contact (circle) Phone Message Office Visit Home |
|Can talk to: 1.____________________________________ 2.___________________________________ |
|Is it O.K. to include HIV/AIDS info in day phone contact? Y N |
|Is it O.K. to include HIV/AIDS info in evening phone contact? Y N |
|Is it O.K. to include HIV/AIDS info in mail? Y N |
|Gender: M / F / Trans |
|Ethnicity: White / African-American / Hispanic / Native American / Asian-Pacific |
|Marital Status: S / M / P* / D / W Household Size: |
|Comments: |
| |
| |
| |
|Employed: Yes / No Name of Employer: |
|HIV Positive? Yes / No / Date of Test: / / Test Location: |
|AIDS Diagnosis? Yes / No Date of AIDS Diagnosis: / / CD4: Date of CD4: / / |
|Client Statement of Needs: |
*Partner
b. Screening for Medicaid and Other Programs
1. Indicate the results of the Medicaid verification:
| |Eligible | |
| |Y/N |Date / / |
|Medicaid Cap C Program | | |
|Medicaid Cap DA Program | | |
|Medicare | | |
|Dually Eligible for Medicaid and Medicare | | |
|Medicaid HMO | | |
2. Indicate Other Program Participation.
| |Eligible |
| |Y/N |
|ADAP - AIDS Drug Assistance Programs | |
|AICP - AIDS Insurance Continuation Program | |
|North Carolina Health Choice for Children | |
|WIC – Women, Infants and Children and Nutrition Services | |
|HOPWA – Housing Opportunities for People With AIDS | |
|Local Indigent Programs | |
|Department of Social Services - | |
|Emergency Assistance Program | |
|Veterans Administration | |
|Department of Social Services Food Stamps | |
|Subsidized Child Care | |
|Employment Securities Commission | |
|Other | |
3. Insurance Information
|Do you have any other health insurance? Y N If no, skip to next section |
|Is your health insurance through your current or previous employer? |
|If through your previous employer, DATE Cobra coverage began: / / |
|Name of Insurance Company: |
|Address: |
|Phone: ( ) |
|Group #: Policy #: |
c. Client Financial Assessment
| Y/N |Income |Amount |Notes |
| |Unemployed | |How Long: |
| |Wages or Salary: | |Name of Employer: |
| | | |Address: |
| |Tips | | |
| |Self-Employment: | |Name of Employer: |
| | | |Address: |
| |Social Security Benefits | | |
| |Temporary Assistance to Needy Families | | |
| |Program | | |
| |Worker’s Compensation | | |
| |Unemployment Compensation | | |
| |Other insurance benefits | | |
| |Trust Fund | | |
| |Retirement Benefits | | |
| |Assistance given by relative and/or friends | | |
| |Income from rental of personal property | | |
| |Other monthly assistance from welfare agencies, | | |
| |public or private | | |
| |Child Support and/or Alimony received | | |
| | | | |
| | Total Annual Income | (A)| |
1. Name and amount of income for all adult family members 18 and over
Name Relationship Amount of Income
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| | | |
| |Total Annual Income |(B) |
Add __________ +_________ = ____________
A B Total Income
Determine a client’s family size and gross family income on the Federal Poverty Guidelines and locate the poverty level percent that corresponds to the client’s gross income and family size on the Federal Poverty Guidelines.
2. Check which documentation provides proof of income and attach copies to this form:
|Type of Income |Documentation |
|Employment Income |____ Pay check stub for the past month, |
| |____ Signed employer statements with dates, |
| |____ Position and phone number or income, |
| |____ Tax return |
|Child Support Payments |____ Court Order/Copy of Check |
|Social Security (SSDI, OASDI) |____ Social Security Award Letters |
|Supplemental Security Income (SSI) |____ Statement/Award Letter |
|VA Benefits |____ Statement/Award Letter |
|Retirement Benefits |____ Award Letter/Copy Check |
|Interest income or other investment income |____ Bank Statements |
|Other Cash Support |____ Family and Friends |
| |____ Other Appropriate and Related |
|Other | |
| | |
| | |
d. Residency
YES NO
| | | |
|The person is living in the state of North Carolina at the time of the | | |
| | | |
|eligibility determination: | | |
| | | |
|Client provided the following as proof: | | |
|A physical living address (as well as a mailing address if the two | | |
|are not the same): | | |
| | | |
|The person is a resident of North Carolina | | |
| | | |
|If no, the person was referred to_________________________ for | | |
|additional services. | | |
| | | |
e. Must Be Willing To Sign All Forms and Provide Eligibility Documentation
YES NO
| | | |
|The person is willing to sign all forms and provide all appropriate | | |
| | | |
|documentation to assist with the eligibility determination process in an expeditious | | |
|manner. | | |
Eligible ________ Y ________ N Comments: _______________________________
________________________________
Client Signature: _________________________________ Date: ______________
Case Manager: __________________________________ Date: ______________
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