Health Insurance (All clients): Head of Household (HOH) Member 2 Member 3 Member 4 Member 5 MEDICAID MEDICAID MEDICAID MEDICAID MEDICAID MEDICARE MEDICARE MEDICARE MEDICARE MEDICARE State Children’s Health Insurance State Children’s Health Insurance State Children’s Health Insurance State Children’s Health Insurance State Children’s Health Insurance Program Program Program Program Program Veteran’s Administration (VA) Veteran’s Administration (VA) Veteran’s Administration (VA) Veteran’s Administration (VA) Veteran’s Administration (VA) Medical Service Medical Service Medical Service Medical Service Medical Service Employer-Provided Health Employer-Provided Health Employer-Provided Health Employer-Provided Health Employer-Provided Health Insurance Insurance Insurance Insurance Insurance Health Insurance obtained Health Insurance obtained Health Insurance obtained Health Insurance obtained Health Insurance obtained through COBRA through COBRA through COBRA through COBRA through COBRA State Health Insurance for Adults State Health Insurance for Adults State Health Insurance for Adults State Health Insurance for Adults State Health Insurance for Adults Private Pay Health Insurance Private Pay Health Insurance Private Pay Health Insurance Private Pay Health Insurance Private Pay Health Insurance Indian Health Services Program Indian Health Services Program Indian Health Services Program Indian Health Services Program Indian Health Services Program Other Other Other Other Other If Other, Specify: If Other, Specify: If Other, Specify: If Other, Specify: If Other, Specify: ____________________________ ___________________________ ___________________________ ___________________________ ___________________________ Income
Health Insurance (All clients): Head of Household (HOH) Member 2 Member 3 Member 4 Member 5 MEDICAID MEDICARE State Children’s Health Insurance Program Veteran’s Administration (VA) Medical Service Employer-Provided Health Insurance Health Insurance obtained through COBRA State Health Insurance for Adults Private Pay Health Insurance Indian Health Services Program Other If Other, Specify: ____________________________ MEDICAID MEDICARE State Children’s Health Insurance Program Veteran’s Administration (VA) Medical Service Employer-Provided Health Insurance Health Insurance obtained through COBRA State Health Insurance for Adults Private Pay Health Insurance Indian Health Services Program Other If Other, Specify: ___________________________ MEDICAID MEDICARE State Children’s Health Insurance Program Veteran’s Administration (VA) Medical Service Employer-Provided Health Insurance Health Insurance obtained through COBRA State Health Insurance for Adults Private Pay Health Insurance Indian Health Services Program Other If Other, Specify: ___________________________ MEDICAID MEDICARE State Children’s Health Insurance Program Veteran’s Administration (VA) Medical Service Employer-Provided Health Insurance Health Insurance obtained through COBRA State Health Insurance for Adults Private Pay Health Insurance Indian Health Services Program Other If Other, Specify: ___________________________ MEDICAID MEDICARE State Children’s Health Insurance Program Veteran’s Administration (VA) Medical Service Employer-Provided Health Insurance Health Insurance obtained through COBRA State Health Insurance for Adults Private Pay Health Insurance Indian Health Services Program Other If Other, Specify: ___________________________ Income
HMIS_TLP%2C_PSH%2C_SPC_Family_Discharge_Form_-_7.2__1.docx