Non-Cash Benefits Assessment Questions IS THIS HOUSEHOLD RECEIVING ONGOING BENEFITS AS OF THE INFORMATION DATE? Yes No CDNK CR to provide IF NO – IF YES indicate which of the following non-cash benefits have you received over the last 30 days –Please Fill In HOPWA only HOPWA Only Source of non-cash benefit If YES Approx Start Date m/d/yyyy If no, explain All services full Client not eligible Food stamps or money for food on a benefits card Applied: pending decision Monthly Amount of Benefit = $ ____________.00 CR the benefit Benefit does not exist Unknown MEDICAID or State-Funded Equivalent, specify: ____________________ All services full Client not eligible Applied: pending decision MEDICARE health insurance program CR the benefit Benefit does not exist AIDS Drug Assistance Program (ADAP) Unknown COBRA Health Insurance All services full Client not eligible Applied: pending decision Employer Provided Health Insurance CR the benefit Benefit does not exist Private Pay Health Insurance Unknown Ryan White medical assistance All services full Client not eligible Applied: pending decision Children’s Health Insurance Program (SCHIP) CR the benefit Benefit does not exist Veteran’s Administration Medical Services Unknown All services full Permanent Rental Assistance -Section 8, Public Housing, or other Client not eligible Applied: pending decision CR the benefit Temporary Rental Assistance Benefit does not exist Unknown TANF child care services All services full Client not eligible Applied: pending decision TANF transportation services CR the benefit Benefit does not exist Other TANF-Funded Services Unknown All services full Client not eligible Applied: pending decision WIC Nutrition Program for Infants, and Children CR the benefit Benefit does not exist Unknown All services full Client not eligible Applied: pending decision Other source (explain) _______________________________________ CR the benefit Benefit does not exist Unknown
Non-Cash Benefits Assessment Questions IS THIS HOUSEHOLD RECEIVING ONGOING BENEFITS AS OF THE INFORMATION DATE? Yes No CDNK CR to provide IF NO – IF YES –Please indicate which of the following non-cash benefits have you received over the last 30 days Fill In If YES Source of non-cash benefit HOPWA only Approx Start Date m/d/yyyy HOPWA Only If no, explain Food stamps or money for food on a benefits card Monthly Amount of Benefit = $ ____________.00 All services full Client not eligible Applied: pending decision CR the benefit Benefit does not exist Unknown MEDICAID or State-Funded Equivalent, specify: ____________________ MEDICARE health insurance program AIDS Drug Assistance Program (ADAP) All services full Client not eligible Applied: pending decision CR the benefit Benefit does not exist Unknown COBRA Health Insurance Employer Provided Health Insurance Private Pay Health Insurance All services full Client not eligible Applied: pending decision CR the benefit Benefit does not exist Unknown Ryan White medical assistance Children’s Health Insurance Program (SCHIP) Veteran’s Administration Medical Services All services full Client not eligible Applied: pending decision CR the benefit Benefit does not exist Unknown Permanent Rental Assistance -Section 8, Public Housing, or other Temporary Rental Assistance All services full Client not eligible Applied: pending decision CR the benefit Benefit does not exist Unknown TANF child care services TANF transportation services Other TANF-Funded Services All services full Client not eligible Applied: pending decision CR the benefit Benefit does not exist Unknown WIC Nutrition Program for Infants, and Children All services full Client not eligible Applied: pending decision CR the benefit Benefit does not exist Unknown Other source (explain) _______________________________________ All services full Client not eligible Applied: pending decision CR the benefit Benefit does not exist Unknown
Coor_Assess_Intake_Ind_P.docx