Health Insurance: Head of Household IF NO (*Note: This is NOT Required except for HOPWA Type of Insurance Programs) YES / NO applied; decision pending applied; client not eligible did not apply insurance type N/A client doesn’t know client Medicaid / HUSKY A, C, D refused applied; decision pending applied; client not eligible Medicare did not apply insurance type N/A client doesn’t know client refused applied; decision pending applied; client not eligible State Children’s Health Insurance did not apply insurance type N/A client doesn’t know client Program – HUSKY B refused applied; decision pending applied; client not eligible did not apply insurance type N/A client doesn’t know client Veterans Administration (VA) Medical Services refused applied; decision pending applied; client not eligible Employer-Provided Health Insurance did not apply insurance type N/A client doesn’t know client refused applied; decision pending applied; client not eligible Health Insurance Obtained through did not apply insurance type N/A client doesn’t know client COBRA refused applied; decision pending applied; client not eligible Private Pay Health Insurance did not apply insurance type N/A client doesn’t know client refused applied; decision pending applied; client not eligible Indian Health Services Program did not apply insurance type N/A client doesn’t know client refused applied; decision pending applied; client not eligible State Health Insurance for Adults did not apply insurance type N/A client doesn’t know client refused applied; decision pending applied; client not eligible Other (specify): did not apply insurance type N/A client doesn’t know client ____________________________ refused
Health Insurance: Type of Insurance Head of Household YES / NO IF NO (*Note: This is NOT Required except for HOPWA Programs) Medicaid / HUSKY A, C, D applied; decision pending applied; client not eligible did not apply insurance type N/A client doesn’t know client refused Medicare applied; decision pending applied; client not eligible did not apply insurance type N/A client doesn’t know client refused State Children’s Health Insurance Program – HUSKY B applied; decision pending applied; client not eligible did not apply insurance type N/A client doesn’t know client refused Veterans Administration (VA) Medical Services applied; decision pending applied; client not eligible did not apply insurance type N/A client doesn’t know client refused Employer-Provided Health Insurance applied; decision pending applied; client not eligible did not apply insurance type N/A client doesn’t know client refused Health Insurance Obtained through COBRA applied; decision pending applied; client not eligible did not apply insurance type N/A client doesn’t know client refused Private Pay Health Insurance applied; decision pending applied; client not eligible did not apply insurance type N/A client doesn’t know client refused Indian Health Services Program applied; decision pending applied; client not eligible did not apply insurance type N/A client doesn’t know client refused State Health Insurance for Adults applied; decision pending applied; client not eligible did not apply insurance type N/A client doesn’t know client refused Other (specify): ____________________________ applied; decision pending applied; client not eligible did not apply insurance type N/A client doesn’t know client refused
HMIS_AIDS_HOPWA_Individual_Discharge_Form.docx