Temporary Rental Assistance $ Other Source – Specify Source _____________________________________ $ Is Client Covered by Health Insurance? Doesn’t Know Refused Not Collected Covered Health Insurance Type (Check all that apply) MEDICAID MEDICARE State Children’s Health Insurance Program Veteran’s Administration (VA) Medical Services Employer-Provided Health Insurance Health Insurance obtained through COBRA State Health Insurance for Adults Private Pay Health Insurance Do you have a disability of long duration? Doesn’t Know Refused Not Collected Disability Type Expected to be of long-continued Documentation of Currently and indefinite duration and the disability and Receiving substantially impairs ability to live severity on file? Treatment or independently Services? Physical Doesn’t Know Doesn’t Know Refused Refused Doesn’t Know Doesn’t Know Refused Chronic Health Condition Doesn’t Know Doesn’t Know Refused Refused HIV/AIDS Doesn’t Know Doesn’t Know Refused Refused Mental Health Problem Doesn’t Know Doesn’t Know Refused Refused Alcohol Abuse Doesn’t Know Doesn’t Know Refused Refused Disability Information (cont.) Drug Abuse Doesn’t Know Doesn’t Know
Temporary Rental Assistance $ Other Source – Specify Source _____________________________________ $ Is Client Covered by Health Insurance? Doesn’t Know Refused Not Collected Covered Health Insurance Type (Check all that apply) MEDICAID MEDICARE State Children’s Health Insurance Program Veteran’s Administration (VA) Medical Services Employer-Provided Health Insurance Health Insurance obtained through COBRA State Health Insurance for Adults Private Pay Health Insurance Do you have a disability of long duration? Doesn’t Know Refused Not Collected Disability Type Expected to be of long-continued and indefinite duration and substantially impairs ability to live independently Documentation of the disability and severity on file? Currently Receiving Treatment or Services? Physical Doesn’t Know Refused Doesn’t Know Refused Doesn’t Know Doesn’t Know Refused Chronic Health Condition Doesn’t Know Refused Doesn’t Know Refused HIV/AIDS Doesn’t Know Refused Doesn’t Know Refused Mental Health Problem Doesn’t Know Refused Doesn’t Know Refused Alcohol Abuse Doesn’t Know Refused Doesn’t Know Refused Disability Information (cont.) Drug Abuse Doesn’t Know Doesn’t Know
exhibit-d-eshap-interim-data-requirements-20161.docx