Health Coverage Screening Sheet

Contact Information

Nombre *

Middle Name

Last Name *

Address *

City *

Zip *

Telephone *

Language *

Household Information

How many children are you applying for (number of children)? *

What are the children's ages? (separate children's ages with a comma, for example: 2, 10, 16.) *

Do any of your children have health coverage?: *

Yes

If yes, please indicate the number of children currently on Healthy Families

If yes, please indicate the number of children currently on Private Insurance (Purchased):

If yes, please indicate the number of children currently on Employer-sponsored insurance (Through work)

If yes, please indicate the number of children currently on No-cost Medi-Cal

If yes, please indicate the number of children currently on Share-of-cost Medi-Cal

If yes, please indicate the number of children currently on Restricted Medi-Cal (Emergency services only)

Which Health Plan has been chosen? (If other children are enrolling in Medi-Cal or Healthy Families)

Is anyone in the home currently pregnant?: *

Yes

Earned Household Gross Monthly Income (before taxes):$ *

Referral Information

What is the name of the organization that referred you?

Contact name

Telephone Number

Notes

By providing this information, you give permission to be contacted by a Certified Application Assistant from Cover the Kids: *

Yes, I understand

Date *

Current Domain