Covered by Health Insurance Do household members currently have health insurance? Yes No Client Does Not Know Client Refused     If No - Do you need assistance in applying for Health Insurance? Yes No   Continue to the MCO question and Health Insurance Sub-Assessment Medicaid MCO or Health Insurance Provider:  Aetna  Blue Cross (BCBSIL)  Cigna  County Care  Harmony  Humana  Illinicare  Meridian  Molina  NextLevel  Out of State  United  Not Applicable (N/A) Complete the following (You may if all household members receive the benefit) Start Date use “All” Medicaid Yes No If Yes, Household Members:  Medicare Yes No If Yes, Household Members:  Illinois Health Insurance Program) All Kids (State Children’s Yes No If Yes, Household Members:  Services Veteran’s Administration Medical Yes No If Yes, Household Members:  Employer Provided Health Insurance Yes No If Yes, Household Members:  Health Insurance obtained through COBRA Yes No If Yes, Household Members:  Private Pay Health Insurance Yes No If Yes, Household Members:  State Health Insurance for Adults Yes No If Yes, Household Members:  Indian Health Services Program Yes No If Yes, Household Members:  Other Yes If Yes, Household Members:  If to Other, Specify Source: “Yes” end of health insurance questions Do you have a case worker with the Illinois Department of Child and Family Services (DCFS)? If yes, you might be eligible for housing assistance through DCFS. Yes No Not Applicable    Have you ever been involved in the child welfare system? Yes No Not Applicable   
Covered by Health Insurance Do household members currently have health insurance?  Yes  No  Client Does Not Know  Client Refused If No - Do you need assistance in applying for Health Insurance?  Yes  No Continue to the MCO question and Health Insurance Sub-Assessment Medicaid MCO or Health Insurance Provider:  Aetna  Blue Cross (BCBSIL)  Cigna  County Care  Harmony  Humana  Illinicare  Meridian  Molina  NextLevel  Out of State  United  Not Applicable (N/A) Complete the following (You may use “All” if all household members receive the benefit) Start Date Medicaid  Yes No If Yes, Household Members: Medicare  Yes No If Yes, Household Members: Illinois All Kids (State Children’s Health Insurance Program)  Yes No If Yes, Household Members: Veteran’s Administration Medical Services  Yes No If Yes, Household Members: Employer Provided Health Insurance  Yes No If Yes, Household Members: Health Insurance obtained through COBRA  Yes No If Yes, Household Members: Private Pay Health Insurance  Yes No If Yes, Household Members: State Health Insurance for Adults  Yes No If Yes, Household Members: Indian Health Services Program  Yes No If Yes, Household Members: Other  Yes If Yes, Household Members: If “Yes” to Other, Specify Source: end of health insurance questions Do you have a case worker with the Illinois Department of Child and Family Services (DCFS)? If yes, you might be eligible for housing assistance through DCFS.  Yes  No  Not Applicable Have you ever been involved in the child welfare system?  Yes  No  Not Applicable
SubCook_Initial_Intake_Assessment_20181001.docx