 Primary English Spanish Other, specify: Language Primary Disability: Start date:_____/ _____/_____ Yes No Client does Client refused Data Not not know to provide Collected Disability Determination:      If YES, expected to be of long-continued, and indefinite duration and substantially      impairs ability to live independently. Is the Above Condition going to be long term? Yes No   End Date: _____/ _____/_____ Secondary Disability: date:_____/ _____/_____ If the client has more than 2 disability please add the information to the back of this form RIN (Recipient Identification Number) ____________________________________ • What health plan are you enrolled in? ____________________________________ • Data Not Client does Client refused Yes No Collected not know to provide Have you visited your primary care      physician within the past 6 months? Where have you gone most often to seek medical care in the past 12 months? •
Primary Language English Spanish Other, specify:  Primary Disability: Start date:_____/ _____/_____ Yes No Client does not know Client refused to provide Data Not Collected Disability Determination:      If YES, expected to be of long-continued, and indefinite duration and substantially impairs ability to live independently.      Is the Above Condition going to be long term?  Yes  No End Date: _____/ _____/_____ Secondary Disability: date:_____/ _____/_____ If the client has more than 2 disability please add the information to the back of this form • RIN (Recipient Identification Number) ____________________________________ • What health plan are you enrolled in? ____________________________________ Yes No Client does not know Client refused to provide Data Not Collected Have you visited your primary care physician within the past 6 months?      • Where have you gone most often to seek medical care in the past 12 months?
Universal_Intake_Form_-_9-2017.docx